Luxair F50 Crash: Pilot's Fault

[LEM]

I just watched the tv: they've issued some sort of final report:

"Total lack of coordination, planning, started the approach when not ready, violated all the rules in the manuals..."

I personally never got to know what happened exactly.
Any informed colleague?

[answer=42]

extract from technical report (not final version, apparently):
http://www.rtl.lu/news/temp/luxair/

[opsmaneurope]

Talking to friends in LUX earlier this year I understood it was pilot error, however this was compounded because LG hadn't carried out a modification to prevent the such happening.

[ATC Watcher]

Sorry folks but I read the " causes" part as shown in the web site more as a total failure of the Airline in providing training, proper CRM, and in distribution of essential info to their crews, rather than just " Pilot error " .
Of course it will always ultimately be the guy at the control who screw things up, but why and how did he arrive to this is the crucial question.
I guess some heads are going to roll at Luxair if what we read in the web site is indeed in the final report .

This sounds very similar to the collision in July 2002 in Ueberlingen.. first blame the persons at the controls,( Swiss controller or even Russian pilot ) but the failures were largely in management as the final report will show.

[411A]

Management flying the aeroplane ...(think not).
If pilots cannot keep the blue side up, it is hardly the fault of 'management'.

How about...inattention as to what they (the pilots) were actually doing.

:yuk: :yuk:

Wonder just when some pilots (providing they survive the crash) will start to actually wake up to the fact that, IF you are not up to speed, excuse yourself from the profession.

It would seem that common sense has gone out the window, especially with the 'lets talk it over' CRM crowd.
Horsepucky...fly the aeroplane, period.

[Wizofoz]

411A,

So I guess when YOUR operation is up and running (chortel, guffaw), you won't be providing such non-essentials as training, SOPs, CRM etc. You'll just wait for your Dino-Jets to spud in and then tell the enquiry "It was the crews fault".

Good luck getting insurance.

[acmi48]

the properties on the link are a .jpg file which means that somebody who understands english is of an airline background and connected has got his hands on something and used it for whatever reason

as far i know there is no official report yet as the case received and extended time from 1 year to publish .something smells around this

[answer=42]

Luxair reaction to leak of draft report (http://www.luxair.lu/en/press/press_full.jsp?id=1685)

The following is from today's 'Le Quotidien' (no website that I can find):

Final report will be published 15 December.

Henri Grethen, Transport Minister said,
'The role of the Ministry is to verify that the licences are in order.' ... 'There is no text that says, to my knowledge, that the two pilots must be trained at the same school and must follow the same in-service training.' ... 'I am convinced that we have done what was required.'

This is my translation, the French text says,
'le rôle du ministère est de vérifier que les licences sont en règle.' ... 'Aucun texte ne dit, à ma connaissance, que les deux pilotes doivent être formés dans la même école et suive la même formation continue.' ... 'Je suis persuadé que nous avons fait ce qu'il fallait faire.'
Usual newspaper disclaimer applies.

[411A]

Wizofoz,

Management is responsible for providing the proper training, however cannot have a check pilot on every line flight.
IF line pilots fail to follow the standard operating procedures as required by the company, accidents happen.

Many examples in the past to prove this.


PS: Operating already, two aircraft...more added shortly.

[acmi48]

..there is an element of nepotism involved.. however the final result will always be.. the culture of those that feel the necessity
to be a figure head.in this case i would let sleeping dogs lie..and cast a caring word to those that lost the lives of someone they loved.the ALPL of luxembourg airlines in this case are right to ask for caution in the case of the aviation community


luxembourg is a safe place and the aviation community is united towards a safe and efficient air service.others who exploit this kind of incident do so for means far more sinister means

[DUKE101057]

I have a question.

Paragraph 3.2. Causes of the preliminary report reads: “The initial cause of the accident was the acceptance by the crew of the approach Clearance, also ….” Shouldn’t this be rather “The initial cause that TRIGGERED the accident was the acceptance by the crew of the approach clearance…” Personally I’d really hard to believe that this late and wrong decision may be THE CAUSE for a fatal accident …wrecks would pile up in final approach sectors? – Who never ever did wrong in his whole carrier? A CAUSE had brought you down too – did it?

Now, my question: Considering the facts listed under Contributory Factors, item number 4 of the same report, and considering the facts on the cockpit voice recorder and the flight data recorder, what had happened under exactly the same circumstances if:

A. ABSC SB F050-32-4 had been satisfactory complied with.
B. If only the vital safety information from the manufacturer to the operator, regarding the inherent risks of a potential loss of the secondary stop on the propeller pitch control had been forwarded in a satisfactory manner to the flight crews.

My mind is made up and accidents like this are only caused by people pretending in a self sufficient way that their place is safe, dear acmi48! It is more than time to wake up your dogs now since this hasn't even been the last in a long, long row of commercial flights accidents in little Luxembourg’s history!

[ATC Watcher]

411A my congratulations, when you comment on something you always manage to atract dozen of responses on a different issue.

Good luck with your copy of flying tigers, I'll be happy to jumpseat with you once the TSA relaxes its rules.

Now back to the topic, I agree management cannot put a check pilot behind every pilot, but if they ****ed up that big ( still to be proven BTW) then something is wrong with either the training , but surely with the profeciency checking mechanism wouldn't you say ?

Reading the annexes, and the CVR transcript ( at least this is not biased normally ) the key issues are laying in analysing the noises between 09.05.17 and 09.05 .25 when the capt says : " What is that ?" followed by the usual " Oh **** ! " just prior the end of the recording.

Do you believe that 2 pilots switched their 2 engines out on purpose or knowingly in that portion of the flight ?
If they did not, then we better find out what happenned and advertise it around to make sure no-one makes the same sequence of inputs in the future.

[411A]

ATC Watcher,

.
TSA absolutely has nothing to say about it.

Regarding the Fokker 50, wonder if someone here would comment on the procedure of selecting idle thrust in flight with these engines.

[alf5071h]

It is difficult to understand how the ‘leaked’ causes and recommendations have been assembled from the factual report. I assume that the missing parts of section 3 of the draft report will give an analysis and explain the logic used in the investigation, but on the data seen so far there appear too many illogical or flawed deductions.

I hope that the final report / investigators will address the following issues:
Did one or both propellers go into beta range during flight causing the aircraft to reduce airspeed (150-115), pitch nose down (-1 to -15), and loose altitude (2750 – 2100) such that the aircraft ultimately hit the ground? Thus this could have been a loss of control accident due to having reverse thrust in the air and ‘bunting’ (-0.5g) at low altitude. Following an apparent upset the crew may at a very late stage shut down one engine (fuel flow zero, LH prop rpm 5). Could they have encountered misleading power plant indications causing them to suspecting a failure? The crew appeared to be taking some corrective action – flap up and pulling nose up (less negative g: the elevator trace and lateral acceleration not shown).
A more extreme consideration would be that a pitch down after lowering flap is symptomatic of tail plane icing – recovery by pulling hard and retracting flap; is this to be formally discounted in the report?

What has not been clearly explained (or is not yet established / published) is why the propellers were in the beta range. Was this due to technical failure, or crew error in combination with a technical weakness (16 sec vulnerability when lowering the gear), or indeed a greater combination of these or other technical / organizational failures?
What is the logic in citing the crew’s late change of plan to continue the approach got to do with the cause other than they wished to slow down, they selected flight idle thrust, and lowered the flap and gear? If the technical weaknesses existed then the crew was just as vulnerable on this approach as any other.
Were the crew aware of the warnings about inadvertent or deliberate in-flight beta selections; how were they trained, did the documentation come with the aircraft?

Even with a comprehensive explanation and that in extremis the crew made an error, the rationale for the error must be presented before the recommendations can imply poor CRM or individual crew behavior. If the crew (crews) were inadvertently selecting beta in flight then an FDR monitoring program should have identified it, but so too would a LOSA program; furthermore LOSA would explain why the error was occurring. Deliberate, inadvertent, technical or a combination. Human error will occur in most operations; crews / organisations do not make errors deliberately, there is usually a complicated background to each event. What were the backgrounds to the errors in this accident?

I find it hard to understand why the anti skid manufacturer’s modification was only ‘optional’. Were they were more concerned about publishing that the mod was at the operator’s expense as opposed to closing down a safety weakness? It is not clear that the national authority mandated (must do) the mod, nor that they gave sufficiently strong advice about in flight beta awareness and avoidance training. Thus is an oversight program (Recc 4.3.1.1) equally applicable to the authority; as they audit the operators?

I hope that these points are answered with the publication of the final report. What the industry needs is information as to why crews make errors in emergency / unusual situations, not more reasons to blame them (and retrain them). The industry depends on the accident investigators to deliver this data.

Keep monitoring this thread.

[Captain Stable]

411A, selecting idle thrust is a matter of routine - as it is on any aircraft.

[411A]

Capt'n Stable

If you had flown many older heavy turboprops, you would undoubtedly be aware that idle thrust in flight (except during the landing maneuver) was definately not recommended, due in some engines to undesirable effects with the propellor reduction gear, with direct drive engines...for example RR Dart series.


My question is directed at those that actually have operated the Fokker 50...

[RatherBeFlying]

411A, I do not recall any cautions against idle selection in the Air Canada Viscount manual (RR Dart powered).

Except that the descent rate would approximate that of a brick;)

[xyz_pilot]

For info

On the F50 there is no restriction on the use of flight idle in the air.

The pw's dont have the Darts G/Box prob.

[JW411]

I spent ten years of my life being dragged through the skies by 4 RR Darts and I don't remember there being any problem about coming right back to the FFPS (flight fine pitch stop) apart from the rate of descent that this would cause. (I seem to remember that we would have between 200 and 240 torque on an average approach).

What you absolutely had to remember was that the ground fine pitch stop had to be engaged after landing before opening the throttles again otherwise all four engines would melt down very, very quickly!

[411A]

xyz_pilot.
Thank you.

JW411,

The FH227B flight operating manual (as well as some models of the Fokker F.27 contained a restriction on using flight idle due to rapid wear to planetary reduction gearing in the engine. In addition, the F.27 Mark 400 contained a restriction for engine ops between 12,500 and 14,000 rpm due to undesirable airframe vibration.

All of these models were Dart 7 powered.

Considering the falling brick scenario mentioned with regard to the 'ole Dart engine when in flight idle...and considering further that the F.50 did just that, made like a falling brick after flight idle was selected, perhaps a restriction in the AFM would be a good idea.
If a turbine engine enters a sub-idle state, or propellor pitch stops fail to work as advertised, acceleration might indeed prove difficult.

[Captain Phaedrus]

411A, not very impressed by your posts. Worst sort of 'management pilot' by the look of things, from where I sit. ..and I can't help recalling the last 'chap' who posted all over this site with the wonderful plans for his airline...

(...and it took you 35 years to get to the office, did it?)

There are no restrictions on setting idle on the F50, in flight or on the ground (strong tailwinds up the jet pipe gave a problem, but obviously, not in the air).

May I suggest that you, and others, take a look at Dr Simon Bennett's (ahem) seminal 'Human Error - by design?', which gives a good academic brief on much of what is under discussion here...

[safetypee]

My understanding of the differences between engines is that the Dart is a fixed shaft turbine and the PW 125 is a free turbine. Each engine having different operating characteristics and operating techniques. I also suspect that the prop control systems differ, thus different modes and ranges of prop angles (including beta range).

Whereas the Dart could be safely ‘disced’ in the air other prop engines could not and in some cases the resulting aerodynamic pitch change could be hazardous. In this accident it is inferred that the PW 125 prop should not have been in the beta range in the air, and apparently safeguards were in place, yet it appears that the engines were in the beta range with disastrous effect.

Some of the basics of the different types of turboprop engines are in a specialized turboprop version of the PSM+ICR (Propulsion System Malfunction and Inappropriate Crew Response) Training and Awareness Guide which was issued recently (CD-ROM last year; joint FAA and UK CAA distribution?) any web links out there?

[JW411]

411A:

I never flew anything with a Da7 only the larger Da8 and we had no such restrictions.

In fact our normal climb power was 14200/730°TGT so that would have been a bit close to your 14000 limit.

[Dani]

After carefully reading through the preliminary report incl. ammendment I come to the conclusion that:

1. The crew was not established and not ready for the approach. They tried to bring down the aircraft to lower altitude by all means.

2. The aircraft was not equipped with the newest updates, so it was possible to go in beta mode inflight.

3. After crew tried to descent very steep they came into beta mode and both engines stopped.
It is nearly impossible to restart in such a short period of time.

4. Due to low visibility is was not possible to emergency land the F-50 on the hillside. ROD was too big to keep integrity of the structure.

What do you suggest?

[pigboat]

The way I read the prelim report is like this.
It would seem the crew was indecisive about carrying out the aproach due to fluctuating vis. They postponed the decision to fly the the approach right up until the very last second when the vis came up to landing minimums. As a result, they were high and fast. In order to configure the aircraft for the approach, they pulled the power back to flight idle. It would appear that due to an electrical fault somewhere in the system, with the throttles closed the propeller flight fine pitch stops were removed, allowing either one or both propellers to go into beta range.
I couldn't read the report posted here - kept getting an 'unable to read this document' from Adobe Acrobat - but I read it in French on another board some time ago. How many holes in that analysis?

411A, you're right about the Dart and min torque. RR recommended a minimum of 60 psi torque in flight due to layshaft chatter.

[m&v]

boat,I think it was little higher than 40lbs of torque,I think it was in the area of 60lbs,to avoid the blade running the engines.
Cheers:O

[pigboat]

m&v yer right. I was too lazy to go look it up. Just did.:uhoh:

[Roxy]

Old F27's used to be 40Lbs of torque to save the layshaft bearings in the gearbox's!
Dead easy to melt down though!

[Daysleeper]

I've never flown the F50 but with more than a couple of years on turboprops here's my two pence worth.

dani, pigboat

operating at close to minima it is not unusual to commence the appraoch and decide to continue it or not at the last possible moment (final fix or lower if allowed by state approach ban minima) hoping for an improvement in RVR.

Flight idle with discing props is quite normal way of reducing speed/ height rapidly. One of the benifits of a turboprop over a jet is the ability to do this. We used to be able to keep 250 knots clean to 5 miles and still be stable by 500 feet on a visual approach. ( need a bit more space in low vis but the luxair guys had plenty)
once the prop entered beta mode in flight they were effectively dead, the weather becomes irrelevent, loss of control becomes almost inevitable.

The key in this is the failure of Luxair to implement the mod to the antiskid system and the failure of the regulatory authority to mandate the mod.
:(

[alf5071h]

Dani

Your first point could be made with a different emphasis. The crew had been prepared for an approach, elected for a go around, then changed their minds. A classic human error, but was this aided by a failure to adhere to the approach ban (RVR less than required at FAF), or the manner in which ATC updated the RVR - were ATC trying to be helpful (no blame, just human nature).

As an aside what is the JAA Cat 2 RVR minima, I though that it was 350m? The crew quoted 300m and the JEP gives 300 but with a reservation about US Ops Specs, what does this mean to a JAR-OPS operator?

The crew having recommenced the approach may have faced an unusual technical situation, probably due to error, oversight, or latent failure. The crew may have seen unusual or misleading engine parameters. Assuming the same power lever angles, there were marked differences between power-plants in torque, engine speed, prop speed, and ITT. It is unadvisable for a crew to attempt diagnosis at a late stage of what had become a rushed approach, and they may well have been IMC at that time. However remember the human desire to perform well and help others; in this case was it trying to maintain schedule for an on time arrival? For any accident where it is concluded that pilot error is the cause, then start the investigation again; there is usually a much deeper cause which often involves human error at individual, operator, and organizational levels. Human error, if identified, can be explained and, defenses placed or alleviating action taken. I hope that the investigators identify the errors.

I do not agree that both engines stopped. Both engines had good ITT and HP and LP rotation. Correcting my earlier post; one propeller stopped (not engine), left hand; it was feathered or nearly feathered. What is not clear from the report is whether this was due to crew action or something else. In the report there is some attention to the propeller over-speed system. The FDR indicates that the RH prop was at or near the over-speed limit, which would reduce fuel flow, but the FDR shows the LH fuel flow reducing towards zero with corresponding LH LP/HP turbines and ITT also reducing. I hate to think that DFR data has been transposed, (or even the possibility of engine display data reversed). We must wait until the investigation finally reports, but I hope that all of these issues are explained.

Many of the problems in this accident appear common with those explained in the PSM+ICR project report, well worth reading, if only to remember that not all aircraft/props are the same and that in particular some of the latest big prop engines should not be selected into beta range in flight.

Edit by ALF after final report: both engines were shut down at a late stage; the FDR had stopped due to loss of elect power.

[minimumclean]

Before you can solve a problem, you need to know what THE problem is. In this case (as usual) a lot of contributing factors were a fact, but not THE problem.
So, what was the problem???? The pilot(s) went below flight-idle, THAT is the problem! Why?? High, close, fast etc....
But why did they go below flight-idle?? Fokker issued a bulletin about this many years ago (after the klc-crash at ams...), warning the pilots!!
And there IS some kind of a detent on the flight-idle setting (and nothing wrong with flight-idle in-flight, you can even select Go-around on the ERP so the props act like speedbrakes).
Sounds like a "get-home-itis" to me, and therefor defenitely piloterror!
My thoughts go to all the family involved!

[411A]

Also seem to recall that the Captain was rather low on experience....age/hours.

The Europeans seem to have the opinion that, it all depends on training. A low hour guy can do just as well as a more experienced type.
What a few seem unable to grasp is that training, altho very concentrated and complete, can not, by itself, substitute for experience and airmanship.
And never will.
Many airlines /corporate operators in the USA found this out a long time ago.

[RatherBeFlying]

Extract from preliminary FDR data:9:05:00 Reduction of engine power -- Torque L-17% R-15%

9:05:09 Start lowering Flaps -- Torque 0%

9:05:16 Start lowering gear -- Torque 0%

9:05:17 Left prop blade goes below 10 degrees-- Torque 0%

9:05:18 Right prop blade goes below 10 degrees -- Torque 0% Looks to me that they were doing just fine in Flight Idle for 16 seconds until the gear lowering unblocked the low pitch:(

[pigboat]

RbF, sure looks that way. It would appear there was some kind of electrical fault in the squat switch circuitry that allowed the flight fine pitch locks to be withdrawn while the aircraft was airborne with the throttles closed.

Daysleeper, agree completely with your comment re close in approach decisions. If there are any pilots on the board who hasn't been in that situation, he's indeed fortunate.

[Daysleeper]

411A

four thousand hours with almost three thousand on type at 26 years old is not low experience, the only thing that suprises me about the captain was that he was still on the F50 and hadn't cleared off to a Boeing, just shows how poor the job market has been in the last few years.

[411A]

On the other hand Daysleeper, the crew definately seemed unsure of their intensions with regard to the approach (or not)...whereas a more seasoned Captain might well have decided that, due to the airfield conditions, further holding or diversion would have been a better idea.
Company culture plays apart here, as does the fuel state (or lack thereof).
A possible suggestion might be for enhanced LOFT training, so that crews are not rushed into approaches...as they positively never should be.

If you ask yourself...does this picture look right...?, it probably isn't.

[answer=42]

Captain is son of former Luxair chief pilot.

[Daysleeper]

What's your point 42?

411 "Seasoned"

The bloke has probably made 1000 approaches into luxembourg in the F50 over 7 years, it gets pretty foggy there every winter so if that is not enough experiance then what is.

Back to the point,
Regardless of what the crew did or did not do, if the prop goes into beta when you put the gear down on approach you are going to crash. Whether in VMC or IMC with 5 hours on type or 50,000 it becomes academic.

[411A]

A thousand approaches into Luxembourg you say, Daysleeper?

Ever hear of the old phrase...'familiarty breeds contempt'?
A bad conbination for a yourger guy, especially

[willbav8r]

Never argue with a fool - he will bring you down to his level and beat you with experience...........

[flt_lt_w_mitty]

Never-the-less, Willb, you have to admit it is A bad conbination for a yourger guy, especially :cool:

[ATC Watcher]

I was told this afternoon that the final report will be released on Dec 15. Those who have seen the latest version say its current conclusions are rather direct and very critical to both the pilots and the airline.
wait and see.:(

[spuis]

Hi,


Looking through the report, I'm still wondering what the position of the power levers was during the last part of the approach.
I can't seem to find whether the levers were in flight idle, or below that.
This is a rather important part, since there is also a mechanical lock on the levers preventing inadvertent selection of power below flight idle.
Did the props go into beta range at gear down selection because the mechanical lock was lifted, and the (non-modified) anti-skid system signalled spin-up? Or was there a fault in the Power lever angle measering as well?


Spuis

P.S. 4000 hours for a turboprop captain doesn't seem inexperienced to me.

[alf5071h]

Spuis
There doesn’t seem to be any data for power lever angle on the FDR. However the propeller low pitch parameter indicates that the beta mode was engaged (or available?) for approximately 16 secs; this appears to be coincident with gear lowering, the reason given in the report.

Thus as your post suggests the mechanical lock was lifted and the secondary device was not available due to some other cause yet to be determined. I assume it to be normal practice for the crew to select flight idle, relying on the mechanical lock to prevent beta range in the air. The crew may or may not have been aware of the design weakness that lifts the lock for 16 secs with gear lowering. If the crew believed that the aircraft was modified then the need for awareness during gear lowering was not required. There does not appear to be any evidence that the crew lifted the lock; I could accept that the timing of the low pitch indication with the gear down is circumstantial, but the engine parameters indicated idle, descent was commenced, and flap selected much earlier, thus I hope that the logical conclusion ties the lock to the gear.

Some crew may have detected that the power levers were displaced further rearward than usual, I do not know what the physical dimension is, but many crews in high workload situations have missed similar cues and also ‘forget’ any awareness of design weakness if applicable. Thus at best it may be concluded that the crew were unwise to continue the approach with changing circumstances, but I suspect that there are some of us who have done something similar, and probably all of us wish that we had the wisdom of hindsight after poor judgment.

[spuis]

ALF5071h,


What I was aiming at is the following:

Were the power levers selected below flight idle (thus lifting the mechanical stop, or it being broken), or was there a fault in the PLA pick-up (sensing ground idle with power levers actually being in flight idle.

On the F50 the range from flight to ground idle is approx. 3-4 cm.
We will just have to wait for the entire report.


Spuis

[ortotrotel]

When 411a talks about experience, I actually concur with his philosophy. While 2800 hrs TOT is not to be sneezed at, his total time and age would suggest that he has not faced a diverse range of operational conditions and experiences, from which maturity evolves.

Being experienced in a narrow spectrum of the industry can lull a driver with lots of TOT into a false sense of accomplishment.

411 sounds (like any pilot who has bent a little metal...) as though he values this diversity in work experience to make calculated risk-assessments - but not in a rushed context. This is an error commonly made by "inexperienced" pilots.

I will expect this to be a causal contribution to the accident.



The Canadian MOT encourages us to learn from the mistakes of others, as we probably won't live long enough to make them all ourselves...

[RatherBeFlying]

Spuis, As I mentioned before, the preliminary report shows the crew reduced power to 0% torque and did not encounter prop pitch below 10 degrees for 16 seconds until the gear began coming down.

Once the first prop went into low pitch, they were in the air for only another 11 seconds if one takes the end of the CVR as time of impact.

[alf5071h]

ortotrotel

Whilst not disagreeing with your observations on total hours and experience, it would be disappointing for ‘inexperience’ to be given a contributing factor in this or any accident.

At some stage in our flying careers we have been or still are, inexperienced. Thus taking your point to the extreme then all of us may contribute to an accident; that contribution I suggest is not one of inexperience, but of human error.

Inexperienced pilots, either by low hours or by less exposure to a range of situations may make different mistakes from those made by the more experienced pilots. We all make mistakes; it is more likely to be the way that the more experienced pilots mitigate their errors or recover from mistakes that prevents their accidents. Thus the problem for the industry to solve is how to provide the less experienced crews with error detection, mitigation, and recovery techniques. Whilst previously this was seen to be airmanship, regrettably today it requires more rules and procedures with the associated loss of flexibility.

The accident investigation needs to identify the specific errors that contributed to this accident and the causes of the errors.
“There are no such things as accidents. What we call an accident is the effect of some cause which we did not see” - after Voltaire

[alf5071h]

Re Safetypee’s request for a web link to the Turboprop version of the PSM+ICR training guide. I cannot find any link via the FAA or CAA, but the following key documents are posted at this site; Turboprop PSM+ICR (http://uk.geocities.com/[email protected]/alf501h.htm)

PSM+ICR report summary.pdf
engine types.pdf
propeller fundamentals.pdf
asymmetric flight.pdf
simulating engine failure.pdf

I suggest 'right click' and 'Save Target as' for downloads.

[My 737]

Nov 6th 2002,
A sad day for everyone, the final report can be found here.

Final Report. (http://www.etat.lu/TR/aviation/acc/Finalreportwoappendices.pdf)

Let those who lost lives and their families rest in peace.

We can all learn from this, find better ways and try prevent series of events like these happening.

Brgds.

[Superpilut]

And if you want to have the additional 114 pages of annexes look here: Report Annexes (http://www.etat.lu/TR/aviation/acc/Finalreportappendices.pdf)

[PropsAreForBoats]

Quote from the final report:

Not withstanding the existing recommendations and procedures, it appears that intentional override of the primary flight idle stop on turboprops in flight is not excluded.

The existing design of the Fokker 27 Mk050 does not prevent the selection in flight of the propeller pitch setting below the flight idle regime.

This is in my opinion an important lesson from this accident, and something all pilots of the Fk50 and similar turboprops should review.

[alf5071h]

I am pleased to see that the very comprehensive final report addresses several human factors issues that contributed to the accident. The report identifies blatant errors and places them in context of an operational accident; unfortunately this was not an operational accident and thus the investigation has chosen an inappropriate primary cause. There is also a short fall in the human factors investigation by failing to give an understanding, or at least a theory, as to why the crew shut down both engines.

The report gives the primary cause of the accident thus: (my italics, assuming ‘initial’ means primary from the translation) The initial (primary) cause of the accident was the acceptance by the crew of the approach clearance although they were not prepared to it, namely the absence of preparation of a go-around. It led the crew to perform a series of improvised actions that ended in the prohibited override of the primary stop on the power levers. Even with the care shown in this report why do investigators in general fall back on the operating crew for being the primary cause of an accident?

This crew was the unfortunate (possibly deficient), last link in the error chain. This accident was waiting to happen; any one of a number of previous crews who, if they too had violated the flight idle restriction (which may have been common practice) during the critical 16 secs during gear selection at low altitude may have lost control. It would at best be speculative to suggest that any other crew would have handled the unique flight characteristics resulting from full in-flight reverse and the associated confusing engine displays in any better way than did the accident crew.

Thus the primary cause from an engineering perspective could have been stated as the loss of control due to both engines giving reverse thrust or a combination of reverse and engine shutdown.

Yet in reality the primary cause was the complete failure of the safety management system, from the authority at one extreme to individual crew at the other. The safety system was riddled with assumptions, allowed violating behavior by both individuals and organisation, and lacked the use of error checking or mitigating techniques.

The aircraft crashed because the right engine remained in reverse, the left engine was shut down, and then the right engine was shut down. The failure to explain or present a theory as to why the crew shut down both engines deprives the industry of further understanding human error. (I accept the difficulties due to lack of recorded data).

As the result of assumption, error, personal failing, and many other reported circumstances, both engines were in reverse in the air. The crew sensed that something was abnormal (seat of the pants), deceleration, pitch down. They certainly heard abnormalities in prop speed (probably the dominant cue) and had confusing engine indications: very high prop rpm, increasing engine speed with flight idle selected. The crew apparently detected the error, the recovery action was unsuccessful (right engine remained in reverse).

Immediately prior to engine shutdown the crew would have had a gross thrust abnormality, the right engine remained in reverse, but the left was recovering to give positive thrust, thus the crew might have been expected to detect a right hand engine failure (dead leg dead engine from rudder input), but why was the left engine was shut down first, and then later the right?

The engine indications were split, the left engine had lower values than the right; there was no evidence that the crew detected an engine failure or called for shut down drills. Thus was the left engine shutdown by mistake?

The problem was compounded by the short time period; was the right engine shut down because of prop over speed - the failure to recover from beta range. Then why shut down both engines, was each engine was shut down by different crew members? It is the details of these actions that are the key factors that led to the crash.

If both propellers had been recovered to normal flight range then the aircraft may well have continued in a flyable condition i.e. the accident would not have happened; yet this issue is not included in the discussion, or the reason for the right propeller failing to recover from beta range (except in appendix 22). A recommendation should be at least to brief crews that having entered beta range if they then required full power (baulked landing) the power levers should only be moved forward carefully avoiding slamming to the forward stop.

The answers to the human factor issues could reside in the training programs, in previous / basic training, or other experiences including firewalling power levers or rushing engine shutdown, but these aspects were not investigated in depth. For generic information see the the full PSM+ICR report (http://uk.geocities.com/[email protected]/alf501h.htm) ;human factors issues at 4.2.12 and section 8; ops issues at 4.2.11; training at 7.2 and 7.2.4.

This accident is a lesson for all who think that by passing one defense (flight idle stop) with reliance on another, that they will not be exposed to risk. Whatever the aircraft or engine type, always stay within the limitation of the AFM.

This was a tragic accident that matched most if not all issues that were identified by the PSM+ICR project report. Also the background and the circumstances have been described previously by J Reason in “Human Error” and “Managing the Risks of Organizational Accidents”; unworthy epitaphs for those who lost their lives.

[safetypee]

Flight International reports that the unions oppose the introduction of Flight Data Monitoring (accident report recommendation). Why does the union, the flight crews themselves, have objections to the use of a modern safety aid? Don’t they realize that it is their own interest – improved safety?

If they don’t like FDM, then use LOSA; the crews could run that system themselves in a modified form. Use of LOSA could have identified some of the errors in the F50 accident in time to have prevented it.

[Cfretland]

411A brings up an interesting issue regarding pilot experience. The European philosophy is a little different when it comes to pilot hiering procedures. If you have 300 TT and can pass the VERY important two day aptitude tests/IQ tests, then you have what it takes. They really don't emphesise to much on flight experience, because you will be TRAINED.
The problem with this is that you will be placed in the right seat as a first officer. You are logging several thousand hours of pilot time but everything is SIC time. We all know how easy it is sitting in the right seat, not having to make any decisions and the decisions you do have to make are always "overlooked" up by a captain.
Than one day you upgraded to captain with a lot of total time but perhaps only a few hundred PIC and you are placed with a 300 hour co-pilot.....now suddenly YOU are the one in charge with nobody to back up your actions.
In the USA things are a little different. There you gain valuable PIC expreience by flying cargo/charter/flight instruction etc. There you learn to be in charge and gain captain experience flying light singles/twins before meeting the airline requirements.
I just got hired flying EMB-145 with 2800 TT and 2600 PIC. Currently flying as captain(single pilot) on King Air 200/100/90 and Navajos.
I have learned to make dicisions whitch in my humble opinion is the hard part....not the flying.

[LEM]

I see the cause of this accident from this perspective:

we don't train our Captains to be Great Captains.

In the (very) old days, the Captain was capable of coming back after takeoff if he discovered his preferred brand of whisky was not on board...

Ridicolous for nowadays standards, of course.

But it's on this trait of the character that I want to focus here.
The Captain was and felt like a God, the master of his world.

We all know the culture has changed a lot in the last decades, also because many accidents have been attributed to this kind of behaviour, called machismo.

In Tenerife machismo caused the worst accident ever, right?



Hmmmmmmm... wait a minute.

Can't we say that if the American crew had been more macho, more capable of dominating their environment, less afraid of hurting the controller's feelings, instead of worring all the time about what was going on, they would have grabbed the mike and asked directly to KLM " Hey mate, where the **** are you, be careful we're on the active runway behind you!" ?

What I' m trying to say is that too many Captains today are
weak individuals.
They really have a hard time resisting all the psycological pressures imposed by the system.

I remember when I was an ATR copilot in Europe, I was ashamed by the weaknesses too many Captains demonstrated, even the experienced ones.
The commercial pressures have become so many in this exasperated competitive market, thet it's very difficult to an individual who doesn't have balls to say NO .

Too many accidents have happened because the crew was incapable of saying NO.
Air Florida, dozens of others, and eventually, Luxembourg.

In this last tragedy, the captain was skilled and experienced, but obviously, a weak individual.
Didn't he know that making a detailed briefing before every approach is a must, and especially in CAT II, didn't he know that checking the glideslope (alt vs distance) is a must , didn't he know thet being fully configured with the landing cklist completed before 1000ft in CAT I is a must ???????

Yes, he certainly knew all that.
Selecting reverse in flight was the last stupid action of a desperate individual.

Being strong is hard sometimes, we all know it, and that's where management and senior Captains failed pathetically:
they failed to set an example in everyday operations, to forge young pilots to a certain character, a character capable of saying loudly "Fu*k the schedule, fu*k the fuel consumption, fu*k everybody, I am in command and that's the way I'll do it...".

Nor the Luxair captain nor the copilot had this strenght and ability behind them, and when they accepted the approach clearance they accepted their death sentence.

I'd like to tell a little episode regarding myself, even if I'm a bit embarrassed for obvious reasons, and also for my colleagues:
some months ago, during sim ckrides, our chief pilot put in the same scenario for every crew: engine failure after go around and purposely too early approach clearance for the ILS, about 6 miles from threshold, while in the middle of abnormal cklist and stuff...
Well, after I replied firmly "Negative sir, we are not ready for the approach, we'll call you back when ready in about 3 minutes", he bursted into applause sayind I had been the only one not to fall in the trap (I can imagine what orrible mess followed for my colleagues when they closed to the ILS with still a thousand things to do!).
Embarrassing to tell (no pilot could resist a sense of proudness after such words):O , but what I'm trying to say is: why the hell the others had no force to say NO?

I was fortunate enough to have a strong model, a quite rude Captain who was famous for his bad character, but was definitely a great individual: my father.

The F50 captain also had a Captain father, but certainly of a different nature...


I'm glad he and his son survived the crash, to live forever in shame for those who lost their relatives. :yuk:

LEM

[KmarK]

Safetypee
For info, Flight International only states what Management said, which is not really the truth. FDM is in use in Luxair for about a year already (737 and E145 fleets).

[unwiseowl]

Nice post LEM, agree 100%.

[safetypee]

KmarK, but another quote was that although data gathering was in use on the 737 and E145 aircraft, the data was not looked at i.e. no monitoring; thus, FDM as a safety tool was not in use.

The use of FDM would not have prevented this accident. There is nothing in the crash FDR data that would have shown the human errors that occurred. Right up to the last piece of data the crash may have been avoided; the loss of FDR data was due to both engines being shut down as was the cause of the accident.

FDRs do not answer why a crew would shut down two engines. An alternative LOSA programme might have detected previous instances of less than ideal CRM, rushed procedures, and deliberate or inadvertent lifting of the idle baulk. Detecting these behaviors and taking corrective action may have avoided the accident.

[sky330]

I'll basically agree with you LEM,

As too often, I have seen captains unable too say NO, no to the rushed approach,or.. or, or even no to the stupid rostering that are sometime the initial step on the dreaded path to a incident.

Must I confess, to my whole shame, that I have sometime been one of them? It's soo much easier too yield that to fight everybody alone because nowadays safety seems an obscene word with money the only motto.

But the
"I am in command and that's the way I'll do it..." attitude can easily backfire

Authoritarism should (in my opinon) be banned from the cockit with the weakness of character you denonced.

All is a question of balance and circumstances,
Never said it was an easy job :O

[ATC Watcher]

very good post LEM. You are right about macho behaviour of the past and todays sometimes weak capts .
Just a correction, In Tenefiffe, the Pan am capt did shout " we are still on the runway " or something to that extend but the call was crossed with the TWR call to try to stop the KLM...

[alf5071h]

There is substance in what LEM states, but what the “Captain really means” is that we all require airmanship and need to continuously improve our personal standards. However what about the other crew members? There was an indication in this accident that the co-pilot did appreciate the tight situation, but he was unable to break the Captain’s line of thinking, therefore co-pilots also require additional training.

Try these as examples, taken from Capt (Dr) Bob Besco’s paper “PACE”.

Probing - for a better understanding.
Alerting - the Captain of the anomalies.
Challenging - the suitability of present strategy.
Emergency Warning - of critical and immediate dangers

Probing
Captain, I need to understand why we are flying like this.
Aren't you putting yourself into a corner and aiming to shoot yourself in the foot.

Alerting
Captain, it appears to me that we are on a course of action that is drastically reducing our safety margins and is contrary to both your briefing and to company's SOPs.
It is my function and responsibility to protect your blind spots. I see you are about to walk off a cliff.

Challenging
Captain, you are placing the passengers and aircraft in immediate danger. You must choose a course of action that will reduce our unacceptably high risk levels.
You are about to self destruct. You have the equivalent of a very angry and armed bogey in your six o'clock position. We are all about to get the civil aviation equivalent of a 20 mil enema.

Emergency
Captain, if you don't immediately increase our safety margins, it is my duty and responsibility to immediately take over control of the airplane.
You, your airplane and every one on board are about to be dead meat. I choose not to join you. If you don't immediately cease and desist, I will take the airplane away from you. I owe it to myself, my family, our passengers, and our company to restore an adequate margin of safety.

The complete paper is here. (http://uk.geocities.com/[email protected]/alf501h.htm)
--------------------
Unless specifically authorized everything else is forbidden.

[KmarK]

Safetypee
just to confirm, FDM is installed and is in use, but only on the 737 and E145 fleet. It is not installed on the F50. The processing of the data is done, but since FDM has been introduced only about a year ago, it is still not used to its full capacity.
That management pretends that the pilot union is against the introduction is a mere lie, as you can see from my previous statements. The pilot union asked Management in summer to stop using FDM, as there was a breach of confidence ( see Flight International this and last week), but management did not comply with the request.
As to the reason of the crash, it was not the shutdown of the engines, but the propellers entering beta range that started the fatal sequence. The shutdown, as part of the restart procedure, was rather the attempt to find a way out of the fatal situation. (BTW from the FDR data I can see only one engine (left) that was shut down).

[safetypee]

Kmark thanks for the update on FDM.

I do not agree with your simplified assessment for the reason for the crash – the propellers entering beta range. Both props did go into beta and the aircraft descended, but it appears that at some point the left prop was recovered to the normal range (it was found to be in the feathered position). The FDR stopped at approx 900 ft agl when both engines were stopped.

Thus, as a hypothesis, as we cannot be sure, the aircraft could still have been flown with the right engine shut down and the left working normally. The airspeed remained high, thus there should not have been a problem with control (Vmca/Vmcl). The flaps were retracted to reduce drag. The unknown was if the left engine would have produced enough thrust to over come the drag of the right prop in reverse.

I agree with ALF5071H’s post on 16 Dec. The report confirms that both engines had been shut down, and if a shut down is the logical drill for an over speed, for which there is no evidence that the crew detected or that a drill exists, then only the right engine should have been shut down, certainly not both at 900 ft. No explanation was given in the report as to why both engines were stopped.

For at least one engine this appears to be ICR after a crew induced PSM.

[CR2]

Just found this

23-MAR-04 Strike threat at Luxair?

Luxair passengers could face disruption to flights if pilots and cabin crew vote in favour of strike action. The Wort has learned that the LCGB union has initiated strike proceedings at Luxair, writing to pilots and cabin crew asking about their readiness to go on strike. Union attempts to discuss problem areas with the Luxair management have failed, and employee confidence in the management has disappeared because of its behaviour after the Fokker 50 crash, according to the Wort. The union also believes the management has destroyed the entire safety culture at Luxair.

Link (http://www.station.lu/index.cfm)

[Frangible]

Call me naive, but why aren't F50 systems designed so that it is impossible to enter Beta range in flight, e.g. impossible to do it unless a/c senses it is "on ground"?

I know of several Casa 212s which crashed because the Beta stops were malfunctioning, and when crew throttled back on approach, it went into Beta range, and they were too low to recover. All claims settled out of court though, and the problem was fixed without publicity.

[tom de luxe]

Frangible:
Read the accident report - Luxair didn't implement on their F50s what Microsoft would call a "security update", and thus the Captain of the flight could fiddle with the prop blade angles more than was good for the aircraft (a/c was high and fast when cleared to land at LUX, to slow down Capt. (PF) overrides safety dev., nothing happens at first but then prop blades go to ground idle the moment the FO confirms "Gear down".:ouch: )

CR2:
Yeah, right, safety culture...
(though the sacking of the six pilots/management pilots nevertheless looks like a cover-your- :mad: exercise for the current managment to me)