MK Airlines B747 crash at Halifax

[GotTheTshirt]

How can the insurance assement be issued before the Official Airworthiness Authority report ??

Are they saying they know better ??

I suspect that this is just a financial document as if there is a hold harnmless clause then they will pay out in any event.

[punkalouver]

Actually, I believe they did get mostly airorne...except the tail until it broke off.

[broadreach]

Insurance assessment

When an accident of this magniture happens representatives of the various insured interests will be amongst the first people on the spot. They will usually be independent surveyors, practical people from the industry, with accident investigation experience. They won't stick around for the final details, just long enough to get a good idea in their own minds as to what happened, why, and to what extent the underwriters they are working for are exposed. As much as anybody else, they want to know the truth and their job is to get as precise a picture as possible back to their principals, the cargo or hull underwriters, via an assessment.

The assessment isn't binding, isn't valid in a court of law, isn't necessarily a reflection of what the accident investigation team will come up with. But it's likely to be a decent professional analysis of what happened and of where liability, if any, will rest.

If someone in Spain has seen the assessment it might be reasonable to suspect it was prepared on behalf of cargo interests, since at least a large proportion if not all of the cargo was destined to Spain and could well have been covered there. If so, the surveyor(s) would have been primarily concerned with ensuring there was no evidence of under-declaring cargo weight.

This is all quite natural and expected when an accident happens and insurance has to be paid out. It would be grossly negligent for an insurer not to send someone to check out all the potential liabilities.

Having said that, if in fact the assessment is on behalf of cargo, the surveyor is more likely to have been someone very conversant with cargo, i.e. an experienced loadmaster. And his brief will be to verify that cargo was weighed, loaded, stowed etc correctly. He may have views, facts and even opinions as to the cause of the accident, formed from the inevitable contact with the accident investigation team and with surveyors representing the hull insurers, but if he's at all professional, they're not likely to be expressed in an assessment unless they are indisputable and certain to be included in the final accident report.

[Rockhound]

"Mostly airborne", Punkalouver? I don't think so. Either you're airborne or you're not. In the case of a tailstrike on rotation, I suppose you could argue that, for an instant, you're "mostly" airborne but then you quickly become truly airborne, as the whole aircraft leaves the ground. But in this case, didn't the tail actually drag along the ground until it broke off?
Rockhound

[ShotOne]

It's all very well describing this as a great achievement, Got the T shirt -and I don't doubt that Mr Kruger must be a very hard nosed and capable businessman to achieve what he has -but that should not , indeed MUST not stop us looking hard atwhy so many aircraft with his initials on the tail have crashed.

Does anyone know what the planned flight duty period was for the unfortunate crew at YHZ? It was certainly very long -reported in the Times as being 24hrs! Perhaps legal in Ghana but not in some other places. Pilots DO make mistakes when forced into duties like that -especially if they have positioned on an intercontinental flight before the duty even starts.

[747FOCAL]

punkalouver,

I don't believe flying in ground effect is considered airborne. FAR 25 considers an aircraft out of ground effect when the aircraft has achieved an altitude greater than the length of it's wingspan.

[411A]

Unfortunately ShotOne, long duty periods are allowed by many regulatory authorties.
One company where I worked, used 14CFR121 as their regulations, and I can recall 747 augmented crews (2 Capts, one First Officer, one Flight Engineer) having a duty limit of...24 hours.

Certainly not unheard of.

[hobie]

BR .... many thanks for the "Insurance assessment" definition :ok:

[broadreach]

Hobie, don't mention it. What I wrote was sheer speculative deduction anyway.

I very much liked, and agree entirely with, Captain Airclues's comment:

"Many lessons can be learned even from incorrect speculation and many accidents have been prevented by information gleaned during these discussions."

I think you can bet that the accident investigators and all the surveyors representing the various interests - hull, cargo, individual cargo owners, consignees etc - will have met up occasionally during the first few days after the accident and gradually exchanged views, debated what could have happened and, also gradually, honed their own opinions. Halifax is not exactly large and if you're a surveyor you'll definitely want to be in the same hotel as the rest of the people involved in the investigation. A week, ten days after the accident there will probably be some sort of privately held consensus as to what really might have happened.

You won't see any of those published until after the official accident report is produced. But the industry is not that large and within a month or so, way before it's published, the real reasons or as close as the collective minds are able to reach them, will be known throughout the industry. And the lessons added to SOPs in many cargo airlines. Including MK's.

[punkalouver]

>In the case of a tailstrike on rotation, I suppose you could >argue that, for an instant, you're "mostly" airborne but then >you quickly become truly airborne, as the whole aircraft leaves >the ground.

Or in this case, they became completely airborne when the tail broke off after hitting the berm.

>I don't believe flying in ground effect is considered airborne. FAR >25 considers an aircraft out of ground effect when the aircraft >has achieved an altitude greater than the length of it's >wingspan.

Could be true. But that would mean that the Spruce Goose never got airborne. I'll have to let them know.

[Rockhound]

It's interesting that, according to 747FOCAL, the authorities consider that an aircraft is not truly airborne until its height above the ground at least equals its wingspan. This would mean that a 747 would need to be nearly 200 feet off the ground before it could be considered airborne. This doesn't make much sense to me. Also, I question the reality of ground effect in the case of an ascending aircraft. But who am I to argue with the authorities?
The tail section of the MK aircraft struck the runway twice during its takeoff roll but apparently the aircaft did lift off the end of the runway, i.e. become airborne in the non-FAR 25 sense - but only just because the next instant the sagging tail section struck the berm.
I still don't understand why no one on this thread has addressed the question of why a crewmember advanced the throttles by a significant amount late (around V1) in the takeoff roll, instead of calling an abort. Much has been made of the fact that the crew may have been very tired. At least one of them, though, was not so tired that he didn't notice that the thrust setting was too low. He knew it takes time for an engine to spool up. He knew there was enough runway left in which to come to a stop. Why did he think they could make it?
Rockhound

[ShotOne]

Yes I agree, 411 some authorities do allow long fdp's. I don't know what the Ghana regulations allow, but it does make Mr Krugers claim that their regulations are the "exact same as EU" seem a bit weak.

It is a fact that even the best pilots DO make more mistakes when given such duties...especially if they immediately follow an intercontinental positioning flight.

[punkalouver]

> no one on this thread has addressed the question of why a >crewmember advanced the throttles by a significant amount >late (around V1) in the takeoff roll, instead of calling an abort.

You are a thousand or 800 feet from the end of the runway in a 747 at very high speed thinking you are near your rotation speed. If you reject the plane will almost certainly be destroyed and you have a high chance of dying. If you rotate now and add power(this has happened before successfully to avoid a collision) you may very well make it with little or no damage. Your time frame to decide was equivelant to reading the first few words on this post. I think you will find that many posters here would have done the same. Maybe myself included. The aviation industry teaches us to be go -oriented at high speed.

[McGinty]

Regarding punkalouver's comment that "Actually, I believe they did get mostly airborne...except the tail until it broke off."

If you read my earlier posting on this thread, you would find that aerial photos of the crash site had revealed that the 747's wheels made tracks in the grass all of the long way from the end of the runway to the berm. The wheels never lifted off the ground, irrespective of how many times the tail also touched the ground. To me, this equals "never airborne".

[747FOCAL]

You are not a pilot. You watch movies.

[LastCall]

What kind of a comment is that, 747FOCAL?

If you are replying to McGinty, his observations are valid. I'm a pilot and have operated in & out of Halifax hundreds of times. Whatever point you were trying to make got missed on me. Whatever credability you still had just got blown away here.

I've been following this thread from the beginning with great interest. Lots of good stuff to think about and reflect on has come up from lots of sourses. I once knew M.T. and was greatly saddened by his loss.

Cut the arrogance and stick to the topic.

[747FOCAL]

Lastcall- I don't know where the post went about firewalling the engines and a bunch of other movie crap went but no I was not refering to either of the posts right before your last. Your a bit quick out of the gate aren't you?

Rockhound - Read the FARs, specifically FAR 25. It plainly says right there that a plane is not out of ground effect according to the FAA until it has reached an altitude equal to it's wingspan.

I never said everybody thought that about ground effect. I said I thought that was my understanding.

[Flight Safety]

McGintry is right, the aircraft never really got off the ground, the tire track evidence off the end of the runway and on the berm makes that clear.

Punkalouver, you said:
The aviation industry teaches us to be go -oriented at high speed.
That is exactly why these pilots died in this particular accident, because they were go-oriented at V1, at the end of a chain of events. I personally think that this is one of the most interesting discussion points about this accident.

Regarding "insurance assessments", I don't know why ANYONE would rely of this as contributing ANYTHING factual to this accident investigation. Depending on the integrity of the insurance company, the "assessment" is nothing more than the conclusion reached by the insurers, as to whether they will be liable for a claim or not. In this case, if an "assessment" was made this early in the investigation, then the insurance agent (or company) MAY only be stacking out it's position in a potential claim dispute. This company may not be doing this, but in any case, an "insurance assessment" should ALWAYS be looked upon as a document that's potentially biased, due to the obvious conflict of interest for the insurance company. In any event, the description of the cause (or causes) of the accident will merely reflect the decision made by the insurance company, as to whether they are liable for the claim or not. It shouldn't have any direct bearing on the actual causes, which are best determined by the government's accident investigating agency.

[hobie]

FS ... I agree .... I was hoping the guy who raised the subject of "Insurance Assessment" might tell us all why he considered it to be so important at this time ..... he did tease us all by saying he had seen the assessment :confused:

[broadreach]

FS, entirely agree.

[Gerbils]

broadreach posted: "You won't see any of those published until after the official accident report is produced. But the industry is not that large and within a month or so, way before it's published, the real reasons or as close as the collective minds are able to reach them, will be known throughout the industry. And the lessons added to SOPs in many cargo airlines. Including MK's."

So what did the collective minds have to say about MK's last totalled 747 ? This accident occured more than three years ago and there still isn't an accident report. If broadreach is to be believed everyone here knows the "real reasons" already.

[Rockhound]

What McGinty writes in his last post doesn't square with what Bill Fowler of the TSB stated, as quoted by Capt. KAOS on Oct 15 (p. 5 of this thread):

“There is an indication the aircraft was barely airborne,” Mr. Fowler said at a news conference. “The scrape trail disappears just before the berm.”

Mr. Fowler said the trail struck for the first time about 250 metres from the end of the 2,700-metre runway, then again with about 170 metres to go.

“The indication is there was prolonged contact of the aft fuselage with the runway and off the end of the runway,” he said.

About 300 metres beyond the end of the runway, the tail then struck the earthen mound topped by an antenna and snapped.

“That is what caused the tail to break away from the rest of the airplane … ,” he said. It came to rest near the berm.

Is McGinty now claiming that the main wheels, as well as the tail section, hit the berm?

Rockhound

[broadreach]

Gerbils,

Sorry, I didn't follow the last MK accident and can't answer that specific question. I'd suggest, though, that the 30+ pages on here re the Halifax crash are a good example of the "collective minds" at work.

Whether the thoughts coming out of those minds are worth professional consideration is up to individual readers to judge, but I think the professionals can, each in their field, separate wheat from chaff.

If you go back over this thread you'll find that, early on, much was made of possible overloading. Possible? I'm being diplomatic. As it happened, that was the first thing to be conked on the head by the investigation team.

Then it was MK's working hours. That debate continues and, if the volume of informed comment on here is anything to go by, exhaustion could well be a contributing cause.

What collective intelligence seems to boil it down to, at least so far, is takeoff thrust settings which were not sufficient to get the aircraft off the ground within the field length.

Crew exhaustion is not going to go away because of this accident. You can work against it but, until you win the battle, for now it's a fact of life.

That is the crux of the real message and it will not take the months to come before the official report comes out for tired cargo flight deck people to remind themselves and each other to check again, remember the Halifax MK.

This accident, and this thread, may eventually turn out to be pprune classics in the sense that they have made people throughout the industry think.

A note to Rockhound.
Don't know if the photo's still there in one of the early pages, but it clearly showed gear tracks leading from the end of the runway and becoming deeper on their way up the berm.

(just checked the first fifteen pages and didn't find the photo. It must have been a link from a news site. But the tracks were quite clear)

[hobie]

Early on, we picked up on much being made of the aircraft actually starting its takeoff way down the runway ..... in fact many hundreds of feet shorter than max available ..... we quickly identified that a taxiway could lead the craft to begin its roll some 700 feet shorter than max

this suggestion now seems to have "died a death"

[TheShadow]

http://www.iasa.com.au/folders/Safety_Issues/dfdr-cvr/MK747fhalifax_files/1015a.jpg

[broadreach]

Thanks, Shadow, a thousand words. And a slight correction to my earlier recollection, Rockhound; the photo doesn't show the tracks leading from the end of the runway to the berm so the centre gear may have been a few inches off the ground prior to hitting it.

[411A]

Hmmm, the photo provides a grim reminder that when things go wrong, they can sometimes go very wrong...if you don't pay attention to details.
Just opening up the taps and hoping for the best just ain't good enough...as some operators have found out.

[Rockhound]

Thanks go to The Shadow for putting up that photo again. The left end of the berm fitted between the fuselage bogies and the bogie under the left wing. What are the tracks to the left beyond the berm? Do they belong to the aircraft or another vehicle? Did the under-wing bogies leave any tracks?
Rockhound

[hobie]

Its a good question Rockhound ..... here's a photo of 9G-MKJ
on the nose ...... I can't relate the Halifax photo to it .... what am I missing? ..... have also added a side view link

http://www.airliners.net/open.file/116010/M/

http://www.airliners.net/open.file/658730/M/


http://www.iasa.com.au/folders/Safety_Issues/dfdr-cvr/MK747fhalifax_files/1015a.jpg

[broadreach]

Hobie and Rockhound,

The tyre tracks beyond the berm seem to be from cars or trucks.
The port and starboard wing gear may have hit the top or the berm, or not. The photo doesn't show so, and they would certainly have been within the width of the berm.

If we wanted to finesse, we could debate as to whether the lights on the berm were removed by the undercarriage, the engines or the rear fuselage, but it doesn't really make much difference, does it?

What happened seems pretty clear. A few red herrings have been sent on their way. What led to that happening has now been narrowed down here to a few flight deck scenarios and will eventually be published for all to see, if they're still interested.

And, If I recall correctly, they did use the entire runway. The suspicion that they might have thrown away 700m was laid to rest in one of the earlier threads.

[McGinty]

Rockhound suggests that "What McGinty writes in his last post doesn't square with what Bill Fowler of the TSB stated, as quoted by Capt. KAOS on Oct 15 (p. 5 of this thread).....:"

He goes on to ask "Is McGinty now claiming that the main wheels, as well as the tail section, hit the berm?"

My original post about the wheel marks was on page 18 of this thread, well after the early speculation by Bill Fowler and others.

All that I passed on to readers of the thread was a news report in the Halifax Herald that said the following: "From the helicopter there were no gouges visible in the pavement, but two tire marks in the brown grass led to a line of orange posts [the berm], part of the airport's navigational system."

The origin of my information was therefore not an aerial photo. My apologies for that.

If aerial photos of the grass strip between the runway and the berm do not in fact confirm the existence of the tire marks that the Halifax Herald reporter described, then my apologies for bringing an erroneous report to everyone's attention.

But if the reporter was correct in his or her observations, then the conclusion must be that at least one pair of wheels did hit the berm.

In the photo just posted above by Hobie there do seem to be some wheel marks both below and some distance before the obvious collision point, which is about the 40% of the way from the left of the berm along the white section on the top. There is a line of white debris immediately beyond that berm collision point. Or maybe it is a trick of the shadows that makes me see tire marks there?

Is there no other aerial photo of the ground between the runaway threshold and the berm that would provide better evidence one way or another?

[Rockhound]

I have interpreted the parallel tracks that appear to begin immediately in front of the berm and continue up it to have been made by the two fuselage bogies. Is this correct? If so, the wheels must have contacted the ground before the berm and rolled up (and over?) it. Correct? Those bogies are at the mid-section of the fuselage. However, Bill Fowler stated (I don't think he was speculating) that the tail section hit the berm, so presumably it was dragging. I would have thought the top of the berm would be heavily damaged but it doesn't look like it to me. Were repairs made to the berm immediately following the crash and the photo was taken subsequently?
It does look like they weren't even barely airborne at the berm.
Rockhound

[yotter]

There is so much info on this topic so far, that the following may have already been covered - if so, apologies!
I fly the 747 Classic Freighter although not the -7Q. The method my company uses for calculating EPRs and RTOMs involves the use of runway analysis charts for each airfield - flap 10 or 20 - then entering the ambient conditions for the day. Reduced power is obtained using the assumed temperature method and the actual take off mass. Since we don't have a TAT/EPRL computer, the other EPR limits are also extracted from tables. We then enter the speed tables using actual take off mass against pressure altitude and assumed temperature to give the Vee speeds.
There has been quite a bit of speculation about the power that was actually set and the idea of V1 being reached but a lot further down the runway than it should have been. I suspect that what might have happened is that the crew entered a much lower mass than actual ( eg zero fuel mass ) so that not only were the EPRs too low, but the Vee speeds as well. This would explain why the a/c didn't leave the ground when the pilot rotated, which it should have IF Vr had been reached. Is it possible that the pilot/ flight engineer simply applied go around power when it became obvious that 1.3 EPR wasn't enough?
Another point is that we are usually right at the limit of performance flying freighters - max take off and landing is the norm, so there's little room for error.
Cheers,Y

[RatherBeFlying]

There seems to be a faint bogie track past the berm to the left of a white stripe at a distance which makes the stripe appear to be the continuation of the right prominent bogie track before the berm.

Perhaps a less abrupt slope would improve the odds in the deceleration case, but my preference would be for frangible stopway paving, especially in front of something like a berm.

[clarityinthemurk]

I have not read much comment about the nature of this berm, and its contribution to this tragedy. It seems from what has gone before that the aircraft went over the berm in a nose high attitude, quite possibly with the pilots seeking to get off in ground effect, but then the tail hit this solid mass. So what is such an obstacle doing in what seems to be an otherwise clear clearway? While it is not possible to be anyway certain, had these lights been mounted on frangible posts, there would have been that much more of a chance of a better outcome.

[Rockhound]

Clarity,
Hold on a minute. That berm is located 300 m beyond the end of a 2700 m runway. It can hardly be considered an obstruction. That the berm was hit shows just how woefully, how tragically, short of takeoff capability the MK jumbo was.
Rockhound

[broadreach]

Hmm, yes, Rockhound.

The berm looks to be some four or five metres high and the light posts perhaps another 1.5m. In many other airports from which cargo aircraft operate there are houses 300m from the threshold.

Been thinking about recent posts re whether the aircraft was airborne or not. One, that from the tyre tracks up the berm it was quite obviously not airborne enough and that the efforts to lift off by raising the nose, scraping the tail, may have, through the resulting loss of speed, contributed to her finally not being able to clear the berm.

As to the possible gear tracks beyond the berm, I just can't see any trace from the photo Hobie posted. Either before or after the berm. And I'd expect that the impact of that centre gear, then the rear fuselage, hitting the berm, would be sufficient to punch the gear up into the fuselage and send the aircraft on a huge bounce that only ended where the woods begin or shortly before; that darker area 4/5ths of the way from the berm to the woods may be scorched grass where the first impact after the bounce from the berm occurred. Or it may be just an area where the grass wasn't growing before, cindered perhaps. I really don't think it's worth much speculation.

I think we have to draw back from all this discussion of the berm (remembering it is quite a distance from the end of the runway) and, considering that the aircraft wasn't overloaded, that it used the full runway length, that Halifax is not an unfamiliar stop for cargo crews, let the investigation team come up with its detailed findings. Those findings will include the crew's duty hours prior to Halifax and then, if there's justification, people can start using this accident as a means to draw attention to and, if necessary, correct the system.

[RatherBeFlying]

There are four distinct tracks from just before the berm and then going up the berm.

Possibly each track is made by one bogie -- or each track is made by the wheels on one side of a bogie -- can't say for sure without measurements, but I'm beginning to suspect we're looking at the tracks from all four bogies.

Perhaps somebody can supply the width and/or height of the berm.

So the wheels went up to the top of the berm.

Past the berm the wheels either:[list=1] rolled down the opposite side until the fuselage met the top of the berm and were held off the ground for a distance until the remaining fuselage failed arced in a flattened ballistic trajectory until the rear fuselage collided with the top of the berm[/list=1] The grey debris pattern in front of the berm is consistent with reports of the tail breaking off at the berm, but absorbent material is possible.

[PickyPerkins]

Rockhound Date : 29th November 2004 17:36
I have interpreted the parallel tracks that appear to begin immediately in front of the berm and continue up it to have been made by the two fuselage bogies. Is this correct? If so, the wheels must have contacted the ground before the berm and rolled up (and over?) it. Correct? Those bogies are at the mid-section of the fuselage.
This set me wondering where the other wheels would have passed over or around the berm in the photo posted by hobie.

After looking at a lot of photos on Airliner.net I found the wheel and bogie spacings to be approximately as shown below

http://home.infionline.net/~pickyperkins/Halifax_1.gif

So normally there would be eight wheel tracks spaced as shown above, the pairs of tracks being spaced about 3.4 times as far apart as the spacing between the wheels on a single bogy.

Doing a similar exercise with the photo of the berm re-posted by TheShadow shows the spacings of the wheel ruts to be as shown below:

http://home.infionline.net/~pickyperkins/Halifax_2.gif

So it appears that the two pairs of wheel ruts running up the berm were made by adjacent bogies, probably, as Rockhound says, the center two with the wings of the plane level.

In which case the other two bogies would have passed over the berm as shown below:

http://home.infionline.net/~pickyperkins/Halifax_3.jpg

The smaller images are copies of the rut images in the lower photo, and indicate the relative positions of all four bogies.

This seems to me to show why some of the orange thingees were knocked down and not others, the wings also missing all but one of those not knocked down by the undercarriage.

Photos on Airliner.net of 747s taking off show that the last wheels of all the four bogies seem to leave the ground almost together e.g. http://www.airliners.net/open.file?id=716477

Therefore, for only the center bogies to have made contact with the ground and leave ruts while the outer bogies cleared the berm without leaving marks, the plane must have been in an unusually nose-high attitude.

And for the center bogies to make ruts at the base of the berm while the outer bogies were above and clear of the berm means that the plane mist have been in an exceptionally high nose-high attitude.

I assume that the black blob between the tracks at the top of the berm may have been the position of the final tail strike.

Rockhound posted 28th November 2004 17:54
Thanks go to The Shadow for putting up that photo again. The left end of the berm fitted between the fuselage bogies and the bogie under the left wing.
I think that this statement may not be right, and that Rockhound’s earlier quote at the top of this post is right, i.e. that the outer bogies passed over the berm without leaving marks but knocking down the orange lights.

Two questions: How high is the berm, and how far behind the outer bogies are the inner bogies on a 747? And hence what must that minimum nose-up angle have been? That’s three questions.

Cheers, http://home.infionline.net/~pickyperkins/pi.gif

[ChiefT]

Weight assessment methods, runway information at Halifax and crew fatigue all concern Canadian safety board

The Transportation Safety Board of Canada (TSBC) has written two safety advisory letters to the country's transport department following the 14 October crash of an MK Airlines Boeing 747-200F at Halifax, Nova Scotia. One concerns the data available on the runway slope at Halifax, the other draws attention to assessment methods used to determine the weight of freight pallets loaded with packages at airports where there is no ability to weigh the full pallet.

In addition, the elapsed time from take-off at Luxembourg to the attempted take-off in Canada has been confirmed by the TSBC as 12h 6min. The destination of Zaragoza, Spain would have meant a further 8h crew duty. The same augmented crew, consisting of two captains, a first officer, two flight engineers, a loadmaster and a ground engineer were rostered to perform the entire trip from Luxembourg via Bradley, Connecticut, on to Halifax; and finally to Zaragoza. All seven died in the accident.

Asked whether this was an excessive duty period even for an augmented crew, Ghana-registered MK says that it has since changed its rostering to bring it in line with European practices, but claims this was the result of a study begun early this year, not as a reaction to the accident.

The TSBC says its safety advisory letters do not imply a cause for the accident, but it says that concerns about the quality of data from which take-off performance calculations were made have arisen as a result of investigations into the MK incident.

The TSBC confirms, for example, that pallets of seafood loaded on to the 747 at Halifax could not be weighed when filled, so their weight was calculated as a multiple of the assessed average weight of the packages stacked on it. The aircraft attempted a take-off, but did not get airborne despite two tailscrapes near the runway end, after which its tail hit an earth and concrete bank 200m (650ft) beyond the runway and detached.

The TSBC will not comment on whether crew fatigue might have been a factor in the accident. The board also says that it is not allowed by law to reveal flight data recorder (FDR) information in advance of the accident report, so local press claims that FDR data shows the aircraft began its take-off at a low power setting and only increased it to the planned setting close to rotation have not come from official sources.

S: FLIGHT INTERNATIONAL

[Rockhound]

The inner bogies are certainly well back of the outer bogies but I haven't been able to find a scale drawing of the undercarriage of a B-747 Classic.
Plate 11 in D P Davies's "Handling the Big Jets" (3rd ed) is very instructive. It shows a 747 Classic undergoing high-AOA takeoff tests with a deliberate tailscrape. The hindmost four wheels of the inner (centre) bogies are the only wheels in contact with the runway as the extreme tail scrapes the ground.
Rockhound

[pontius's pa]

I read the early pages of this thread some time ago, came back to the thread today. Could not be bothered with the intervening pages, no doubt much of the same. Found the early pages depressing in that almost all contributors knew little about flying and clearly f...al about the the 747, despite quoting a "747 pilot says" his quoted sayings being mainly rubbish.

Tailstrikes are almost unknown on T/O, a possible hazard on landing if one is not careful with the AOA (means Angle of Attack or Pitch Attitude for many contributors who lack this this basic knowledge) on landing above 12 degrees is really pushing your luck. .

Boeing at the bequest of BA designed an over- rotation warning for TO, installed nowhere else and later abandoned

Now I see people drawing maps on this thread. The Canadian Accident investigators are internationally acknowledeged as being amongst the best in the world. Just wait for their report, meanwhile don't embarrass yourself by trying by guess the out come

If I was sober, I could go on for hours, but trying to type accurately is becoming tedious.

It is threads like this, and there are many of them, that make PPrune look faintly ridiculous.

Some time ago there was a pompous thread, with which at the time I did not agree, that said make this forum for real airline professional pilots only. I now think that maybe he had a point.

Time for bed for me.

rockhound

The dimensions of the 747 undercarriage are laid out on the dimensions page of the AFM.

[hobie]

PP .... any chance you might post a copy of the relevant page from the AFM (aircraft flight manual)

many thanks :ok:

[TyroPicard]

Are you sure these ruts are 747 wheel tracks?

1. To the naked eye they are constant depth. Imagine the impact of the landing gear at about 150 knots - I think the divot would be somewhat larger.
2. They appear to be at a slight angle to each other.
3. The berm is basically undamaged except for the lights.
4. There are four similar ruts towards the right hand end of the berm - but the spacing is wrong for these to be caused by the other pair of bogies.

TP

[Rockhound]

TyroP,
No, I, for one, am not sure, hence my earlier questions. But if the aircraft didn't make those tracks, what did? We know, from what the TSB has released, that the tail section struck the berm, so the undercarriage couldn't have been very high above the ground. The wheels must have been spinning at a great rate, which would cushion the impact with the berm, wouldn't it? And looking at that photo in Davies's book (I don't have a scanner so cannot post a copy. Could someone do so, please?), one can imagine most of the wheels clearing the berm. Still, I admit it is difficult to understand why the berm, if it was struck by the tail section of the aircraft, appears relatively undamaged. Also, why do the (tire?) tracks (appear to) begin only just in front of the berm?
Rockhound

[RatherBeFlying]

There seems to be a debris field (or possibly absorbent material) before the berm that may be covering a longer track before the berm.

Perhaps instead of lights on the top of the berm, it's a localiser array.

Earlier in this thread is an observation that this end of the runway is not visible from the opposite end which may explain why the localiser array had to be elevated.

[punkalouver]

>The aviation industry teaches us to be go -oriented at high >speed.
--------------------------------------------------------------------------------


>>That is exactly why these pilots died in this particular accident, >>because they were go-oriented at V1, at the end of a chain of >>events.


Perhaps this go-oriented thinking did end up making this situation worse, but this type of thinking likely prevents many more accidents due to high speed overruns from happening. Accidents that we are never aware of because they never happened.

[broadreach]

Here's a link to an airliners.net photograph showing the relative position of inboard and outboard gear assemblies. When unloaded the outboard gear hangs lower but the inboard is further back.

With apologies aforehand for my armchair analysis I am going to stick my neck out a bit further and make a guess as to what happens when the centre gear of a fully loaded 747 suddenly encounters a steep gradient which I'm estimating at 4-5m high and very solid. The gear assembly fully compresses and then punches up into the aircraft up just aft of centre, breaking its back. The rear section snaps down and on impact with the object, separates from the front but is carried forward by momentum. All this happens in less than a second.


landing 747-200 (http://www.airliners.net/open.file?id=723378&WxsIERv=Qm9laW5nIDc0Ny0yMzBG&WdsYXMg=T2NlYW4gQWlybGluZXM%3D&QtODMg=THV4ZW1ib3VyZyAoLSBGaW5kZWwpIChMVVggLyBFTExYKQ%3D%3D&ERDLTkt=THV4ZW1ib3VyZw%3D%3D&ktODMp=Tm92ZW1iZXIgMjcsIDIwMDQ%3D&BP=0&WNEb25u=R%2BlyYWxkIEFSTk9VTEQ%3D&xsIERvdWdsY=SS1PQ0VB&MgTUQtODMgKE=V2VsY29tZSB0byBFTExYIQ%3D%3D&YXMgTUQtODMgKERD=MjYw&NEb25uZWxs=MjAwNC0xMi0wMg%3D%3D&ODJ9dvCE=&O89Dcjdg=MjE1OTIvMzQ3&static=yes)

[Flight Safety]

Punkalouver, I basically agree with you. However it appears that in this accident, the normal go response to V1, that works 99% of the time, may have failed them in this instance, mainly due to the fact that they were some distance further down the runway than originally intended, when they arrived at V1.

On most takeoffs (especially field limited takeoffs), you have to reach Vr sometime after you reach V1. In this case it looks like they came very close to making Vr at the berm (well past the end of the runway), but not quite.

Again, I think the go-no-go decision a pilot is forced to make regarding V1, at the point when these pilots discovered that they reached V1 at reduced power, is going to be a 50-50 guess at best. The reason is because too much information (i.e. runway distance remaining, time to spool up the engines to max power from a lower power setting, time remaining to accelerate to Vr, runway distance to cover to reach Vr, etc.) has to be processed in too short a period of time to easily make the correct decision. It's also possible that neither decision will save the day, especially if you're just too far down the runway at the problem discovery time.

Again, the best solution is to avoid getting into this situation in the first place (arriving at V1 too late), and this is the primary lesson that I'm taking home from this accident.

[abra]

With all of Canada's open space..what a stupid place to build an earth wall.Surely frangible ILS antenna posts would be better.I think Sharjah should have invested in a bulldozer to flatten the over-runs of its airfield too.It might save lives.
But then it always amazes me that airport planners go around finding big flat open spaces,and the first thing they do is build an enormously tall tower.What's LHR's new one going to be..300feet?!You wouldn't get me up in that thing for love nor money.

[PickyPerkins]

broad reach ….. when the centre gear of a fully loaded 747 suddenly encounters a steep gradient which I'm estimating at 4-5m high and very solid. The gear assembly fully compresses and then punches up into the aircraft up just aft of centre, breaking its back. The rear section snaps down and on impact with the object, separates from the front but is carried forward by momentum. All this happens in less than a second. ………

TyroPicard 2. They appear to be at a slight angle to each other.This web-page shows the relative positions of the four bogies (on a -400). Click on the picture of the book to get a bigger picture.

http://www.amazon.com/gp/product/customer-reviews/1580070558/103-0346057-9224669?%5Fencoding=UTF8

http://www.amazon.com/gp/product/customer-reviews/1580070558/103-0346057-9224669?%5Fencoding=UTF8

The corresponding photo on the cover of the -200 book does not give such a good view.

It seems almost impossible that the aircraft could have been at such a nose-up attitude high that the front bogies left no sign of impact on a berm 4 m high. But how else can you explain what the photo of the berm shows?

Question: Assuming it was at such a nose-up angle, and nearly at flying speed (and therefore on the ground), what would you expect to see in the way of tracks before the berm?

On the flat ground before the berm I suggest you would see very little because there was little load on the ground - the plane was almost flying. As the leading wheels of the trailing bogies start up the slope of the berm I would expect a large load on the rear wheels and for the tracks to start a bogie length before the slope of the berm starts.

I suggest that is exactly what the photo shows.

The slight divergence of the wheel tracks as they go up the berm might be associated with the progressive collapse of the undercarriage as suggested by broad reach.

Cheers, http://home.infionline.net/~pickyperkins/pi.gif

[TyroPicard]

Even if you point a 747 vertically upwards the wing gear is nowhere near 4 metres above the body gear. From the side, on the ground, each pair of bogies looks like this: OOOO no overlap but not much of a fore/aft gap.

And at 150 kts flying basically level they would make a big hole, not dainty little 3-inch ruts like a Chelsea tractor might.

The Canadians state "the tail hit the berm". No mention of gear. At a high angle of attack, tail close to the ground, I reckon the gear would clear the berm.

TP

[ShotOne]

If it was 12 hrs 6 min from TAKE OFF in Lux, it must have been at least an hour and probably more from report. Is it really legal to roster a 21 hour (at least!) duty even using Ghana regulations??

it does at least go some way to explain how some of the problems detailed on the other thread could have arisen -and dare I say it, how MK have crashed no fewer than three other heavies in the last 12 years

[McGinty]

Just a post to say thanks to PickyPerkins for the detailed analysis of the wheel ruts in the photo of the berm. It was an excellent presentation which I think has led to some interesting further analysis about this plane's position as it passed over/through the berm.

Unlike some others, I think that this kind of theory exploration is an excellent topic for a forum such as this. There are some first class aviation brains who have contributed to this thread. It would not surprise me at all if The Canadian Transportation Safety Board's enquiry into this crash itself might develop some new lines of reasoning as a result of reading some of the informative posts on this thread.

[411A]

Well, for starters, ShotOne, it may well have been.
The FAA for example under 14CFR121, allows a 24 hours duty period for an augmented crew...2 Captains, one First Officer, two Flight Engineers.
Just off hand I can't remember the allowed number of landings, but if memory serves correctly, 4.

I personally know of only one crew that was stretched to this limit, and this was due to MX.

But, to actually roster as a matter of course, seems foolhardy to me.

Twist the tail of the tiger....expect to be severely bitten.

[Max Angle]

Twist the tail of the tiger....expect to be severely bitten. Quite agree with that, unfortunately it's not the people who do the twisting that end up getting bitten.

[PickyPerkins]

TyroPicard Even if you point a 747 vertically upwards the wing gear is nowhere near 4 metres above the body gear. From the side, on the ground, each pair of bogies looks like this: OOOO no overlap but not much of a fore/aft gap.I agree - as I said in my post it seems almost impossible for the outer bogies to have cleared berm while the rear bogies were firmly on the ground at the base of the berm. I have no answer.
http://www.airliners.net/open.file/664530/m

Below a photo of all fully extended bogies is superimposed on the photo of the berm. The width of the tires, the spacing between the wheels on each bogie, and the spacing between the bogies all match. I have no answer as to why the outer bogie ruts do not show up

http://home.infionline.net/~pickyperkins/1015a_wheels.jpg

Cheers, http://home.infionline.net/~pickyperkins/pi.gif

[TyroPicard]

Why not make the theory fit the evidence? The ruts were not made by a 747, but by something else. The berm is covered with traces of similar ruts!!!!!

TP

[broadreach]

Perhaps you're right, Picky. But, just perhaps, there's a little window of AOA where the outboard gear is dangling but still a foot or so above the inboard gear which itself, along with the tail, is only a foot or so off. Just think what might be anybody's gut instinct as the berm looms up in the lights. Do absolutely anything to get over it, right? i.e. pull up even more.

Assume for a minute that might have happened. Desperate yes, but by this time could you expect anything but? It would get the nose and the wings up higher but it would put the tail down, right? And it would put the inboard gear, which is slightly aft of the centre of lift, down as well, right into the berm.

There have been a few posts that seem to suggest the impact of the rear fuselage with the berm should have destroyed the berm. I've forgotten most (sorry, all) of my physics but there are many more tons of earth and concrete in that berm than there are in the tail of an aluminium 747. An aircraft which, granted, can take a lot of punishment but of an entirely different sort.

You whack that centre gear up into the fuselage on a protrusion like the berm and you break the aircraft's back. The rear, with elevators still trying to raise the nose, pressing the tail down, hits the berm and that's it.

This was the result of actions taken or not taken minutes before, as the aircraft prepared for takeoff. I humbly submit that the real issue, and whatever lessons are to be learned, lies in those actions, not in all this discussion of the berm which, as I think I mentioned earlier could, at other airports around the world, well have been houses.

P.S. something that occurred to me a few days ago but thought not worth mentioning. If you're sluggishly airborn and seriously needing speed, what do you do? Get the gear up!? Suppose retraction was initiated before the end of the runway. How does a -200's gear cycle in retraction? Do the outboard bogies fold in first or do they all retract simultaneously? Do the outboard bogies first - or simultaneously - correct the angle of the dangle, so to speak, to bring the wheels into the wells? I am going wildly off track perhaps but if I were designing undercarriage I would try to ensure that the "gear up" sequence" first reduced drag by aligning front and rear wheel sets in the bogie before folding them up into the wing.

IF that's the case, it might be an explanation for the lack of outboard gear tracks up the berm.

[hobie]

"..... not in all this discussion of the berm which, as I think I mentioned earlier could, at other airports around the world, well have been houses"

BR, my local strip is 10,000 feet long and 300 feet from the 06 end the builders left a 12ft high solid bank of rock :{ ..... travel a further 50 feet and the ground flattens out and remains suitable for a "very serious crash over-run" if it was ever required for a couple of thousand feet minimum! ...... but you would never get there! :( ..... the 12ft high rock bank would kill you first ...... To this day, I've never understood why they left the rock there :confused:

If you have lots of open space why on earth leave an imoveable obstacle at the end of the runway? :confused: :confused:

[McGinty]

On PickyPerkins latest photo above, the starboard outer landing gear lines up with damage at the rear of the berm, circled in red on the photo below.

http://www.commerce.usask.ca/faculty/boyd/berm.jpg

[Sqwak7700]

quote:
Quite agree with that, unfortunately it's not the people who do the twisting that end up getting bitten.

I second that. Fatigue is almost always a factor in every aircraft accident in which pilot error is a cause.

I'm not saying pilot error was the cause in this one, but authorities really need to get together and come up with realistic flight/duty times. Given the international nature of air transportation, it should be something that every country must follow.

I love how MK mentions that they are changing this rostering practice on accounts of "safety studies" done before the accidents. I would really like to see them reproduce the documents proving their so called "studies".

[broadreach]

Hobie, I wish I knew. Bureaucracy and budget conspire against what we might think of as practicality everywhere. But is it totally unreasonable to build, say, a berm, for the lights to be mounted on, 200m beyond the threshold? Even if the land beyond is flat and only woods? You and I don't know the extent of airport property; perhaps those woods belong to someone else. And in so many places, 200m would put you in the middle of the sea, or of a densely populated area built up gradually many years after the runway was originally set there.

You have to keep coming back to basics, i.e. that runway lengths are known facts and that, if you're going to operate aircraft in and out of them, those facts have to be acknowleged. For better or for worse, no company can run an airline on the basis of the minimum dimensions or of the forgiving qualities of the safety envelope. If that were the case, would anyone ever have landed at Kai Tak?

Just a thought based on a local airport's movement. I live a stone's throw away from the southern threshold of SDU, Santos Dumont, the downtown Rio airport. 30m from that threshold is a pile of boulders (at the other end there's a ramp leading down into the sea, originally intended for hovercraft) and, beyond that, the sea. Thirty metres, I said. There is absolutely no room for indecision. SDU's no different from so many airports around the world; they each have their own restrictions. Like Halifax.

[RatherBeFlying]

In my fading memory of Davie's chapter on the 747: The wing gear has considerable vertical travel. If only one wing gear comes down, you have to retract it as it will otherwise keep coming down and tip the a/c.

I suspect the wing gear came up on its struts as it contacted the berm while the body gear had less travel. Add to that the flex in the wings as they generate [insufficient] lift. These factors cumulate in less loading on the wing gear.

The removal of the structures on the top of the berm in the path of the wing gear show that it was down there. Note that the nacelles did not take out anything on top of the berm which further indicates that the wing was developing some lift.
The body gear can pivot in taxi turns -- this along with progressive deformation of structure may explain the divergence in the tracks.

[Engineer]

If memory serve me right (last used my Ghanaian Licence 4 years ago) under GCAA rules with a heavy crew

Which was 2 complete crews, but due to the intervention of the now defunct Ghana Airways was amended to 3 Pilots and 2 FEs the max duty period was 18 hours

With a provision to extend to 20 hours due to unforeseen circumstances. The GCAA rules are loosely based on the FAA regs.

[broadreach]

RbF,

Just looked at Hobie's posting of the side view of an MK 747 departing and from that it would seem the gear all retracts at once, not "outboard first, then inboard". And that the outboard gear aligns its "dangle" close to the well rather than prior to the folding-inward motion. So the thought I threw out earlier re an attempt at gear retraction is probably off base.

The only other thought that occurs is that the outboard gear is designed to compress more easily; it's the first to touch the ground on landing and the last to leave the runway. Could it be that the outboard gear actually did ride up the berm but, more easily compressed, without leaving marks discernible in that low-resolution photo?

If the outboard gear didn't touch the berm at all it's back to AoA.

[PickyPerkins]

In a post on 1st December 2004 I asked three questions:

(a) how far behind the outer bogies are the inner bogies on a 747-244?
Answer is 10 feet 1 inch.
(b) how high is the berm?
Answer estimated to be 11 feet 6 inches (3.49 meters).
(c) and hence what must that minimum nose-up angle have been for the outer bogies to have cleared the berm?
Answer is that no angle allows this.

TyroPicard 2nd December 2004 18:37
Even if you point a 747 vertically upwards the wing gear is nowhere near 4 metres above the body gear. From the side, on the ground, each pair of bogies looks like this: OOOO no overlap but not much of a fore/aft gap.You are absolutely right. The front gear is 3.07 meters from the rear gear. The spacing between the wheels on a bogie is about 12 inches, and between bogies as seen from the side is about 17 inches.

broadreach 2nd December 2004 21:46
Perhaps you're right, Picky. But, just perhaps, there's a little window of AOA where the outboard gear is dangling but still a foot or so above the inboard gear which itself, along with the tail, is only a foot or so off. ………..I afraid that the numbers do not seem to indicate that an AOA window could be possible.

TyroPicard 2nd December 2004 21:43
Why not make the theory fit the evidence? The ruts were not made by a 747, but by something else. The berm is covered with traces of similar ruts!!!!!

broad reach December 2004 12:49
……. I am going to stick my neck out a bit further and make a guess as to what happens when the centre gear of a fully loaded 747 suddenly encounters a steep gradient which I'm estimating at 4-5m high and very solid. The gear assembly fully compresses and then punches up into the aircraft up just aft of centre, breaking its back. ……

broadreach 3rd December 2004 18:18
.......... The only other thought that occurs is that the outboard gear is designed to compress more easily; it's the first to touch the ground on landing and the last to leave the runway. Could it be that the outboard gear actually did ride up the berm but, more easily compressed, without leaving marks discernible in that low-resolution photo? ........Maybe the change in the theory should be that either the outer bogies ran up the slope without leaving a detectable track or that they punched up through the wing but the rear ones did not collapse (the grass between the tracks seems to be undisturbed). The outer legs are twice as long as the inner ones, and supported by the wing structure which may be less robust than the fuselage structure.

I estimate that the front wheel of the front bogies at their dangle angle would at near the level of the top of the berm if the rear bogies and the tail were in contact with the ground.

I see shadows of the antenna masts on the berm, but no similar ruts.

The answers given at the start of this post came via page 188 of a pdf document on the www.boeing.com site, “747 Airplane Characteristics, Airport Planning”, May 1984.

Page 188 shows a drawing with a front/rear bogie spacing for 747-200 aircraft of 10 feet 1 inch.

From the same diagram the spacing between the outer wheels of the rear bogies calculates to be 16 feet 3 inches.

The photo of the tracks on the berm show this distance (always assuming that these tracks were made by these bogies) is about equal to the slope height of the berm, i.e. the outer tracks and the top and bottom edges of the berm form a square. If the slope angle is 45 degrees, then the vertical height of the berm is 11 feet 6 inches.

By the way, the wheel spacings which I earlier estimated from photos and posted on Dec. 1st as being in the ratio of 1:3.3:3.5:3.3 are actually (from the Boeing document) 44:141:151:141 inches, a ratio of 1:3.20:3.43:3.20. Near enough.

Cheers, http://home.infionline.net/~pickyperkins/pi.gif

[broadreach]

Gosh, we all seem to be basing so much on a single photograph! And on the unlikelihood of just two centre gear marks apparent on the berm.

What seems most unlikely to me is that the four tracks up the berm shown in the photograph taken shortly after the accident could possibly have been made by anything else that the MK aircraft. Yes, I'll wait for the report but I'll be very surprised if the tracks happen to be from a passing tractor! And I am, of course, intrigued at the lack of outboard gear tracks although there may be just a hint of the starboard gear's passage at the very base of the berm.

It the faint mark of the starboard gear is, in fact, that, where are those of the port gear? Could it be that the outboard gear bogies rode up the berm without leaving marks or, by reason of the greater length of the strut, collapsed and folded back a fraction of a second earlier? The inboard gear certainly wouldn't have had the option of collapse; it would go up the berm or through it.

Another thought. The berm is covered in grass. But the ground underneath is pretty hard at this time of year. If, in fact, the tracks leading up the berm are this aircraft's, just to get that deep might indicate a very heavy impact.

[ShotOne]

If your recollection is correct, Engineer that would put them a good couple of hours outside even the extended max permitted duty period, having taken off from Luxembourg to cross the Atlantic twice.

as an aside why sre folks so strung up on the precise point at which each part of the aircraft hit the ground? Even if the berm hadnt been there the aircraft would certainly have hit the trees a bit further on.

[Rockhound]

ShotOne,
__________________________________________________
Even if the berm hadnt been there the aircraft would certainly have hit the trees a bit further on.
____________________________________________________

How can you be so sure of that?
Rockhound

[PickyPerkins]

ShotOne
.... as an aside why are folks so strung up on the precise point at which each part of the aircraft hit the ground? Even if the berm hadn’t been there the aircraft would certainly have hit the trees a bit further on.While you are almost certainly right, we do not really know that the berm made no difference, do we? The plane was almost flying when it reached the berm.

One the other hand, the accident was well under way before the plane reached the berm so that in that sense the exact events at the berm may not be relevant to the primary causes of the accident.

However, to my mind it is interesting to look at what must have happened. Please skip the following if you have no interest in the details.

The Boeing pdf document “747 Airplane Characteristics, Airport Planning”, May 1984, has a scaled drawing of a 747 which when overlaid on the photo of the berm allows one to see which parts of the plane passed over which parts of the berm. I hesitate to show the drawing here (copyright considerations), but the following diagram shows the results of such a comparison.

http://home.infionline.net/~pickyperkins/TracksOnBerm_B.jpg

Note: In making this diagram:

(a) the plane’s dimensions have been scaled so that the inner wheel tracks in red lie in the four ruts at the BASE of the berm.

(b) the photo has been rotated so that the center line of the fuselage lies along the broad whitish track beyond the berm. I assume that this track was made by the aircraft sliding along the ground either going or drifting slightly to the right of 90 degrees to the berm.

Observations:

(a) when orientated as detailed above, two of the red wheel tracks lie on the right-hand pair of ruts in the photo all the way up the slope of the berm, while in contrast the left-hand ruts diverge away slightly to the left, as though the left-hand undercarriage was beginning to collapse.

(b) the eight wheel tracks in red correspond approximately to the positions of knocked over antenna masts (as has been said before).

(c ) the remaining undamaged antenna masts show that, although the rear fuselage is known to have hit the berm, the wings (purple), engines (green) and tailplane (blue) must all have cleared the tops of these masts.

A little gentler slope to the berm and there might have been a “ski jump” take off.

Cheers, http://home.infionline.net/~pickyperkins/pi.gif

[SimBoy]

This is my first post (nice to be here). I live in Halifax and work at the airport in a regulatory capacity.

As to the thought that a "non-ski-jump" berm might have been a contributing factor in the tragic accident, is it not correct that the lowest part of the aircraft should have been a minimum of 35 feet above any obstacle at the end of the takeoff run (including clearway, as appropriate)? Canadian runways have very strict design criteria. I really do not think that the location, nor angle of the base of the berm, should be considered as a pertinent factor.

SimBoy

[broadreach]

Three thoughts:

1) PP, thanks, you've obviously gone to a lot of trouble on those diagrams and it will no doubt be interesting to compare them with the final accident report. Just one thing we might all take into consideration is that it's extremely difficult to judge, from our distance, all the possible factors that contributed to the accident. It seems to be a given that the aircraft hit the berm and that, at this point, the tail separated. In such a violent collision our theories based on the scant evidence available to us are but chaff.

2) ShotOne, no intention here of getting into the overworking/exhaustion discussion. But stating categorically that the aircraft wouln't have made it past the trees some 300m distant is, er, too categorical. They might have, even with some evergreen boughs in the undercarriage. Or it might have developed into something less lethal, like the Mulhouse A320 accident from which most walked away.

3) SimBoy, tend to agree with you, "should have been" being the operative phrase. We all, sorry most of us, live and learn that what should have been could be a little bit better, had we thought of it earlier. Not suggesting here that Halifax should demolish the berm but yes, perhaps, the airport authority might give some consideration to whether the lighting support could be made a bit less menacing.

[SimBoy]

The berm hosted the localizer antenae for runway 24.

SimBoy

[abra]

I say it again..willy-nilly of all the theoretical talk of 35feet screen heights etc,if it is atall possible,the ends of runways should be clear and flat..maybe covered in gravel or brush of a certain thickness and height.It is the sudden stop that kills.

[Idle Thrust]

Just to set the record straight, simboy is correct - those "red thingies" are not lights, they are the elements of the ILS localizer array.

That ILS was one of the early CAT II installations in Canada and, if memory serves correctly, the berm was built when the ILS was upgraded to CAT II standards.

Maybe the antennae had to be elevated to produce a signal that meets CAT II tolerances, perhaps due to runway slope. In any event I do not recall any indications on airport or runway-specific performance charts that indicated a clearway problem.

[ShotOne]

broadreach perhaps I should have used the word "probably" rather than "certainly" as regards hitting the trees. Either way, as someone pointed out, the accident was well under way by then -and at other airports MK use it would have been buildings and cars

and why don,t you feel the fatigue aspect is worth discussing? surely it could be very relevant in letting us find what went so horrendously wrong in the flight deck that night

[M609]

the ends of runways should be clear and flat.

Should? yes.... Possible everywhere?

.....not at all!!!

[broadreach]

ShotOne,

Agree with you as to "probably". They would have had a marginally better chance.

The fatigue question bothers me because there's a general tendency on here to prejudge, to assume that the crew were fatigued and that that was the main contributing factor. From there to blaming MK for inhuman rostering etc is soo easy.

It may well turn out that this was the case. But the investigation will first be trying to establish what the physical sequence of events was, then whether the sequence was incorrect and, finally, why it was incorrect. And that's when you start considering the fatigue issue.

[ShotOne]

Well doesn't everything on this entire thread come under the heading of pre-judgement? The official report will not be out for some considerable time -indeed I don`t think the report for MK's last crash is even out yet.

We DO know the duty period was very long and would have involved two Atlantic crossings. We do know that this would have been illegal if the aircraft was UK as opposed to Ghana registered and we do know the crew are likely to have been very tired. These are hard facts not speculation like much of what we`ve read here.

Of course we don't yet know the full train of events but I absolutely disagree that the fatigue aspect should be off limits just because we don`t yet know the cause for sure.

[csomesense]

Bill Fowler said investigators' calculations have shifted the probe to the lack of power at takeoff....

The flight data recorder shows the aircraft had a large increase of power just seconds before it attempted to lift off, said Fowler.

"In the latter portion of the takeoff the thrust went up to maximum," he said.

Not up to exactly 1.6?

[broadreach]

ShotOne,

OK, don't want to argue about this so perhaps we can agree to disagree on discussion of fatigue as a contributing factor. In my own simple mind, though, what I see is:

a) the aircraft crashed
b) it crashed because it hit the berm
c) it hit the berm because it wasn't going fast enough to take off
d) it wasn't going fast enough because thrust was insufficient
e) thrust was insufficient because....

and there, for the time being, it rests. Waiting for facts.

Cheers,
broadreach

[ShotOne]

that's nonsense broadreach. If this take off had been attempted at, say, East Midlands (EGNX) it wouldhave hit a motorway embankment. At other MK destinations it would have been buildings. To descibe by your logic the embankment/building/berm as the cause of the accident is not logical or truthful and will not help us pinpoint the cause of this tragic crash.

[broadreach]

ShotOne, pls see PM
rgds,
broadreach

[csomesense]

SNAM,

the reason for my post was that previously on this thread it has been stated by a person that:

"1.3EPR was set instead of 1.6" (p27)
"at no time was the throttle firewalled" (p31)
"I have access to what the average aviation person would not" (p31)
"actual data recordings" (p32)
"exactly what the data recorder says. At no time during the takeoff run were the throttles firewalled..." (p35)

My point was that if the chief investigator, Mr Bill Fowler (who we hope has access to the same FDR as the author of the above statements) comes forward with "In the latter portion of the takeoff the thrust went up to maximum," how much substance can be put in the comments of the author of the statements quoted above?

[Kensiko]

Friday, December 17, 2004 Back The Halifax Herald Limited
--------------------------------------------------------------------------------
Pilot error blamed for jet crash
Cargo plane's throttle set too low during takeoff, TSB says

http://www.herald.ns.ca/stories/2004/12/17/f127.raw.html

[747FOCAL]

That would appear to confirm that I knew what I was talking about. :(

[Flight Safety]

747focal, you did know.

My guess is that fatigue will be a major factor, and it's interesting that MK has now changed from 24 hour schedules. It seems hard at this point, to see how this will be ruled as anything but pilot error. I do hope this creates a major wake up call for the types of schedules that some operators are using. :(

[Geepers Eprs]

Flight safety is absolutely paramount to us," Mr. Kruger said. "We've never cut corners with flight safety."

:*

[Hangin' on]

So isn't it time for a CAA audit of this lot? I know they are registered in Ghana, but they operate out of UK. A review of previous pprune threads shows what could be alleged to be a cavalier interpretation of the rules.:ooh:

[RESA]

. . . first post . . please bear with me . . . sure hope this thing has a spell-checker!!

I have followed this thread with great interest.

I have observed (over the years) that probably 99% of most aircraft accidents have been attributed to human-error (pilot, design, procedures, legislation, maintenance, and operations). In Fact, all accidents probably involve some human-failure factor (that’s why they are called accidents . . . as opposed to an act of terrorism or war).

I do suspect that an error was made that night (early morning) on the flight deck. Why/What . . . I don’t know . . .

I do question why it was necessary to have a 20’ high, 130’ wide earth, rock, and concrete capped mound, supporting a 10’ tall navigation antenna, on the extended centre line of the runway, 1000’ off the end of the runway? This structure has been there for a little more than a year. The prior structure (supporting the previous navigation antenna) was a somewhat frangible structure (gantry . . .collapses when struck).

We all make mistakes . . . surely we can afford ($$$$) to make airport environments where we don’t have to pay for mistake with our lives??? Does privatisation and commercialisation of Air Navigation Systems in the world mean that we must financially compete with 3rd or 4th world nations for the “price-tag” of service delivery?

. . . . I think I’ll star taking the train and boats. . . . .

[747FOCAL]

I did say something, but in respect to the dead I am editting.

[Cejkovice]

The point is that the berm was 1000ft off the end off the runway and not directly at the end. Had it not hit the berm it would have very likely hit the trees just beyond.

In terms of safety it is logical to remove all obsticles around the end of a runway, but in reality in many locations houses & roads are built at an equivalent distance from the runway.

[Tawny Eagle]

I understand that according to ‘Cejkovice’, houses built “1000ft off the end of the runway” is within acceptable terms of safety. I doubt this to be a reasonable thought. Since MK moved mid-August from Manston to Belgium’s Ostend (to the satisfaction of the Ramsgate neighbourhood), the new host airport has four to five MK-movements a day.
The day before the Halifax crash, MK’s Boeing took off in Ostend bound for Luxemburg, from where it started its unfortunate trip using a “heavy crewing” system. I try to imagine what an improper throttle setting would have caused in Ostend after an extra long schedule flight. At either end of the runway houses and shopping centres are built there at the so-called safety distance of 1000ft (even less). An identical crash would have occurred within an urban area.
I learned from local people that Belgian authorities intend to built more houses in the direct vicinity of the runway. It seems that authorities are not impressed at all by the possible consequences of a similar crash. Put this insanity together with MK’s questionable safety improvements to figure out in which catastrophe such a combination might result. A 1000ft safety distance is far from being reasonable.

[broadreach]

Tawny Eagle,

Semantics, perhaps, and pardon me for jumping on your post if my interpretation is mistaken. Cejkovice's comment was, I think, just stating fact, i.e. that a lot of airports have built-up areas within 1,000ft of the threshold. Not that it was safely acceptable.

Anybody the slightest bit concerned with safety - of crews, passengers and local inhabitants - would prefer a 2000m long cone of uninhabited, preferably paved but if not, flat ploughed land, at either end of a runway.

But life isn't like that, is it. Land's expensive and, funnily enough, it's more expensive near airports that have the potential to draw cargo. And local housing/zoning councils have their own agendas, sometimes more short-term and resembling killing the goose than one would like.

[Tawny Eagle]

Broadreach,

I think you are right. I misunderstood. Semantics indeed!

So, Cejkovice, I apologize.

[RatherBeFlying]

The standard minimum distance for a clearway or stopway is 1000'. After that, houses, berms, roads, drop-offs etc. are all permitted as long as they are below the obstruction clearance slope.

If we consider going to the considerable expense of providing arrestor beds before solid obstacles Arrester Bed Examples (http://www.esco-usa.com/com/instal.html) , we come up against the fact that arrestor beds are designed to handle a 70 kt. overrun of a decelerating a/c.

A 747 at 130kt. and full power may well exceed the capacities of an arrestor bed.

[RESA]

I recognise that many airports in the world have a “skin-tight” adherence to obstacle zoning restrictions. This is too frequently due to the lack of “Officials’ ” willingness (balls$) to enforce or legislate restrictions.

I realise that it is sometimes due to a question of topography . . . where else can you put the airport given the mountains, valleys, buildings, etc.!? This was not the case in Halifax

I don’t accept that citing the failures of others is justification or a rationale for taking the cheapest or easiest way out of a design problem.

I also recognise that frangibility and zoning restrictions have had very little impact on reducing the number of recorded incidences of accidents. These restrictions have however, (when properly observed) been significant in reducing the “consequences” of accidents (sort-of the whole idea?).

In this particular incident, the previous antenna was mounted on a structure deemed frangible. The replacement (upgraded) antenna was not placed on a comparably frangible structure. Why? ($$$$$?). Better yet, why not the frangible structure that existed (with some refurbishing)?

There remains some 400 feet plus, of clearway/stopway behind the structure in question, (still on airport property) followed by a hundred feet plus of rather scraggly trees (still on airport property).

(for scale;
- the antennae/concrete slab is ~ 130-ft. wide.
- also, frame centre high, a little right of runway extended centre-line, is the entire tail section of the 747).

http://www.tsb.gc.ca/en/media/photo_database/air/a04h0004/images/a04h0004_photo_2_lg.jpg

(Hmmm . . seems either TSB or PPRune don't like linking their photos?? . . . ASP's a problem? . . . you've got the link . . . take a look)

Looking closely at the 16 antennae sitting on the concrete (the little orange things sitting on the grey slab), it appears that only 9 antennae are missing. The width of the structure that impacted the antennae would appear to be something about 65-ft. or less . . . too small for the wings . . . too big for just the fuselage?

Also note that there appears to be “orange confetti” behind the antennae. The confetti is actually what is left of the antennae (post-impact). Nice that the 10-ft tall antennae were frangible . . . unfortunately, the 20-ft. high mound isn’t.

Zoom in on the centre of the antennae mound. The stuff sticking out in front of the concrete slab (just left of centre-line) is a/c fuselage from the tail impact on the concrete/mound.

If someone is installing or refurbishing an airport facility (ILS), within the airport property, with 400-500 plus feet of airport property clearway/stopway behind you, the antennae facility is fully frangible (in accordance with ICAO’s latest requirements), the existing structure is deemed frangible, all the approach lights around you are required to be frangible (ICAO), why would anyone choose to replace a frangible gantry with a 20-ft. high concrete, rock, and earth mound to elevate the antennae?$?$?$?

[RatherBeFlying]

It's possible the localiser antennae work better off a flat surface than somewhere up in the air. The navaid folks may be able to comment knowledgeably.

I'm not so sure that a berm is cheaper than a gantry as moving that amount of earth and making it stable ain't cheap.

If, for argument's sake, there was a frangible gantry instead of a berm, the prospects for a successful takeoff after going through a gantry would be diminished by the indigestion the engines would suffer as some of the pieces were sucked in.

[poorwanderingwun]

Maybe it's time the authorities re-thought the safety implications and adjusted the requirements to modern aviation....cleared area requirements date back probably to the '50s.... a 744 fully laden has iinertia way beyond anything contemplated 50 years ago....a fully loaded 380 will take us into another dimension (metaphorically speaking for any pedants out there)...one day not too far into the future cargo 380's will be operating regularly out of the same airports....Airports need to be within reasonable distance of the city's they serve...land within that same distance is always expensive as it's considered commuter friendly....ultimately and inevitably safety factors will always be compromised by the financial bottom line....it's an aviation fact of life...

[Mode7]

Hangin' On, MK was audited by tyhe FAA (US and Canadian) and the CAA during the inquiry into the Halifax crash.

[ShotOne]

We're still blaming the berm. This seems a perverse and unhelpful twist of logic. Presumably if this accident had happened at Ostend or some other MK destination we'd be blaming the shopping centre/hill/apartment block/tree unfortunate enough to get in its way. Many airports ARE in built up areas. That's not because of greed. It's because our passengers pay us to fly them to and from where they live.

[MungoP]

ShotOne.......

Exactly my point....In this case the accident would appear to be the result of a mistake by the crew...the cause behind the cause was almost certainly fatigue...but whatever the cause of this event, and there will be others, safety concerns of all aspects of aviation need to be upgraded to allow for developments in the industry.....that includes the airport environment as well as flight duty rosters....out of the two I believe that rostering concerns should be coming under the microsope rather more just now......only changes forced on the companies involved, whether operators of aircraft, airfields or whatever by the regulatory bodies will bring about the improvements....the commercial concerns themselves have to think of the bottom line...changes in regulations at least will ensure that all commercial concerns will be playing on a level field...ultimately the costs will be borne by the clients, and that is how it should be...........

[PickyPerkins]

Well it looks from these photos on the TSB web site that that 9G-MKJ did indeed did make a “ski-jump” take off over the trees to land beyond the road at the left in the second picture below, although by then the aircraft was minus the entire tailplane.
http://www.tsb.gc.ca/en/media/photo_database/air/a04h0004/photo_02.asp
http://www.tsb.gc.ca/en/media/photo_database/air/a04h0004/photo_04.asp
(Sorry to post these photos as links rather than as images but, as someone else also commented, PPRuNe does not seem to like asp files.)

In both pictures the horizontal stabilizer is visible at the start boundary of the trees.
The larger white object in the center of the first photo is the fin, also shown in this picture with the “MK” visible.
http://www.tsb.gc.ca/en/media/photo_database/air/a04h0004/photo_10.asp

The T-junction in the second picture is directly in line with the runway. Click on the caption of the second photo on this page to get an enlarged view of the runway from space.
http://www.cbc.ca/story/canada/national/2004/10/14/plane_halifax041014.html

These picture seem to me to show that the trees between the horizontal stabilizer and the road, and the road itself, are entirely undamaged. So the plane must have passed over them.

So in summary, the plane:
left its wheel marks in the berm,
left the fin between the berm and the trees,
left the horizontal stabilizer at the start boundary of the trees,
the rest of the aircraft must have passed over the trees and the road to crash and burn beyond.

Does anyone else see a different interpretation?

Cheers, http://home.infionline.net/~pickyperkins/pi.gif

[broadreach]

PP, I expect the accident investigation will confirm your analysis. Ski-jump is a good analogy. Had the gradient up the berm really been that of a ski-jump the aircraft might have actually become airborne without breaking its back. Which is what one suspects happened when the main gear hit the berm. The centre of the fuselage would have been projected upwards and the after half of it would have hit the berm at an even greater angle than the aoa during the last few hundred metres of the takeoff run. Thus knocking the heavier tail section off and bouncing the aircraft over the trees and the road, rear hull flapping and engines still at full power, into the quarry beyond.

The whole thing is one of those nightmare scenarios where cause, sequence and outcome seem inevitable. Maybe, because of its slightly higher profile than accidents in Nigeria, Equador or other places that don't attract so much attention, it will nudge operators, regulators and airport authorities.

[targaman]

http://www.emediawire.com/releases/2005/4/emw233476.htm

Comments?

The investigation referred to the Cessna accident at Pelee Island, Ontario is ongoing and TSB Canada has recomended standard passenger weight tables NOT be used on aircraft with 9 or fewer passenger seats.

What about MK Airlines B747, Halifax, Noca Scotia, 14 October 2004.

Loading error? Will the load sheet be used as evidence or a full reconstruction of weight & balance carried out?

As a pilot how do max weight, balanced field, ATM derated field limit take offs on a hot night and a long duty grab you?

I know what I grab!

I would like feedback for my research into weight & balance error as a causal factor in many large aircraft accidents. Email me through www.avibridge.com or www.oacs.homestead.com please.

[barit1]

INS-equipped aircraft have all the raw data necessary to compare ACTUAL aircraft acceleration on TO vs the rate IMPLIED by AFM. Why this has not become a standard go/nogo check is beyond me.

Just one of many examples: Leased Airbus on a Hadj flight, OEI at rotation, barely made it around the circuit to land safely. Aircraft was impounded & everything weighted. Bottom line - the dispatcher was jailed for clandestine shipment of several tonnes of goodies.

There's a simple way to overcome this - measure acceleration. Can't beat hard data.

[Earl]

Some one correct me if I am wrong.
This was a freighter not a passenger plane.
I have done many overweight Haj flights.( passenger)
And many cargo freightor flights.
All were done at max takeoff weights.
Even 8 tons overweight on the 747 classic we got airborne,
The aircraft would not climb or maintain flight planned alltitude even with MCT.
Running the charts in reverse showed us 8 tons over weight.
At destination after dropping our passengers and cargo the aircraft flew right on the charts.
Onthis flight out of Halifax.
The load sheet was done by the loadmaster and checked by the Captain.
He relied on information provided to him by the load planners and loadmaster.
The aircraft load was in the proper configiration as the 747 would show this through the nose gear sensor.
I understand that the cause of this was not the proper EPR setting.
Which anyone can see was way too low.
Maybe I am wrong here but if the proper EPR is not set then this new and improved system wont work.
Back to the basics here.
You cant re-invent the wheel.
I feel for the crew as they were probably tired and did not notice this.
Could happen to any of us!

[BOAC]

but if the proper EPR is not set then this new and improved system wont work - this idea has been aired on PPrune before, and the thing is that it WILL work as the acceleration will not match the requirement for that runway - be it EPR/wt/binding brakes whatever. The only thing it will NOT show, I guess, is that you lined up at the wrong point and are running out of tarmac.

[Earl]

So what is suggested here is some type of runway cross acceleration check?
How about an EPR cross check prior to block.
This crew was obviously tired and missed some things.
EPR was one of them.
Could have happened to any of us.
Hind sight is always 20/20.
As far as an acceleration check I dont think this will come to pass.
Unless you have unreliable airspeed instruments that the MEL requires you to do.
All though if this was added as a techniqe then it would help.
But how many pilots would be looking down at this point instead of the airspeed indicator and the engine instruments and other scans.
Much easier to check the EPR?
But then again you can never have enough information.

[Joetom]

GPS/DME v's EGG timer wired to a go/no go bit of kit and this subject can be history....did they/we put men on the moon.?

[Earl]

No one is ever proud of doing overweight flights.
But when the company you are contracted to constantly lies about the cargo weight it happens.
Things are far from perfect in this part of the world with little or no accountability.

[OverRun]

Earl,

Good words man.

Maybe I'm feeling guilty about the berm. Not mine. But there is one that is. Guess I'd better go get it levelled.

[targaman]

We in the industry (Pilots-Dispatchers) have been using an 85 year old paper based system of weight & balance measurement that is ...........

Read my press release http://www.emediawire.com/releases/2005/4/emw233476.htm

We still (2005) rely on the presumed accuracy of the load sheet when in fact it has been shown many times to be in error.

What is needed is an external aircraft weight & balance system that provides a final check & warning of an overweight and or out of balance condition.

I have patented such as system and am looking for dvelopment funding for a computer model and a prototype for trials in NZ.

Any support from this forum or any other source would be gratefully accepted.

In the MK Airlines case I suspect that once again the load sheet will show a correct weight & balance data. I have made it known to TSB Canada that I am a researcher into what I call the Ice Berg Effect of load sheet error risk to large aircraft and have the support of many accident investigation bodies such as NTSB and TSB. They agree with my concerns but are unable to do anything but make recomendations.

The lack of alternative weight & balance evidence in cases where reconstruction of the aircraft is not possible is a serious concern for all of us.

For those of you interested in more info on this topic visit www.avibridge.com

Keep the discussion going and make your MP aware that the load sheet is still the only evidence available at the scene of the accident in many cases.

Does anyone know if the FDR in your company records weight & balance from the onboard weight & balance system?

I need hard evidence from many sources of the status of your aircraft's OBWBS-active or deactive?

All info will be treated confidentially and is only used in research.

I am free of direct pressure from operators as I am now retired. I know the very real threat for whistle blowers both from a union perspective and from a sole contractors view.

Sorry for the long winded post but I believe it is a serious problem that needs urgent attention. I am doing my bit.

It mayyet prove to be a causal factor in the MK Airlines case.

[Belgique]

Built in Software Traps and Pilot Fatigue
Main features of the Halifax MK Airlines 747F Crash Report

In their report on the Boeing 747 crash at Halifax that killed seven people, investigators say a lack of crew training on new takeoff software, combined with fatigue from working long hours, were likely factors in the accident.

Last year, following the 14 Oct 2004 crash of the MK Airlines cargo jet at the Halifax airport, investigators at the Canadian Transportation Safety Board said the crash was caused by an improper setting of the throttles by a crew member.

As a result, the heavily laden cargo plane, weighing more than 350,000 kilograms, didn't have enough speed or power to make it off the runway.

The tail of the aircraft broke off after striking a berm at the end of the Halifax runway and the plane plunged into nearby woodlands, where it exploded into flames.

But further investigation has turned up problems beyond the throttle settings; specifically the crew's training on new cockpit software, said Bill Fowler, the board's lead investigator.

The software known as the Boeing Laptop Tool, or BLT, calculates the proper speed and thrust of the plane - based on information the crew inputs on weight, the length of the runway and the weather conditions.

Fowler said the software was set for the plane's weight at its previous takeoff in Hartford, Conn. - almost 110,000 kilograms lighter than the Halifax load.

After interviewing MK airline staff, the board concluded the training process on the software was incomplete.

"Did all of the training get done? We didn't feel it was adequate," said Fowler.

"The company undertook to implement this (software) package following guidance material. The question arose: did they do it adequately? In our view, not all of it was."

Fowler said the software could allow the crew to use the previous takeoff's weight data, if they were not familiar with program.

The investigator declined to elaborate further, saying the full analysis on the role training played will become public when the board's final report is published in several months.

When asked about the crew's training in an interview, Steve Anderson, a company spokesman, said the training was adequate.

"We've been using the program for many months prior to the accident. We'd never had any information of any problem from any of the air crew previously," he said from the company's headquarters in Hartfield, East Sussex.

Anderson also disagreed with the investigator's concerns about pilot fatique.

"They'd had sufficient rest at different stages of the journey. It's a simple as that. We don't believe it played a role in the accident."

At the time of the crash, the crew had been on duty for 19 hours. Had they completed their trip, Fowler says they would have been on duty for 30 hours.

In Canada, regulations allow a similar-sized crew a maximum duty period of 20 hours. In the United States and England, the maximum is 18 hours.

As the cargo plane was registered in Ghana, however, MK Airlines wasn't required to follow the North American or British standards.

Anderson said the airline has since increased staff training on the Boeing software and reduced the number of on-duty hours for crew.

Fowler said he can't be absolutely certain a lack of knowledge about the software was the main cause of the error that led to the crash, because the cockpit voice recording of the pilots' final conversations was destroyed by fire.

But he adds, "all of these factors come together, the level of awareness, the training and procedures . . . The best we can do is we can look at it and say these were the factors that were present at the time and we feel they would likely have contributed."

"The BLT and fatigue were significant elements in this."

Anderson said the airline is currently attempting to register its fleet of jumbo jets in the United Kingdom, rather than in Ghana.

"Part of the process of going through that is to have the Boeing laptop tool certified and approved by the U.K. aviation authorities, which has just been completed," said Anderson.

This Friday, the company plans a memorial service in the United Kingdom for the seven dead crew members.

A company official also plans to return to Halifax, where a small memorial will be held.

The dead Britons were Capt. Michael Thornycroft, a resident of South Africa; as well as Capt. David Lamb and flight engineers Pete Launder and Steve Hooper, all residents of Zimbabwe.

Also killed were ground engineer Mario Zahn, a German who lived in South Africa; and loadmaster Chris Strydom and first officer Gary Keough, both of Zimbabwe.

[Rockhound]

The Oct 12 Globe and Mail newspaper reports preliminary findings, just released by the Canadian Transportation Safety Board, as to the cause of the MK 747 freighter crash in Halifax on Oct 14, 2004.
----------------------------------------------------------------------------------
POOR TRAINING TIED TO JET CRASH, PROBE FINDS
By Michael Tutton
HALIFAX -- A year after a fiery crash of a Boeing 747 killed seven people, investigators say a lack of crew training on new takeoff software, combined with fatigue from working long hours, were likely factors in the accident.
Last year, after the Oct. 14 crash of the MK Airlines cargo jet at the Halifax airport, investigators at the Canadian Transportation Safety Board said the crash was caused by the throttle being set improperly by a crew member.
As a result, the heavily laden cargo plane, weighing more than 350,000 kilograms, didn't have enough speed or power to make it off the runway.
The tail of the aircraft broke off after striking a berm at the end of the Halifax runway and the plane plunged into a nearby woodland, where it exploded into flames.
But further investigation has turned up problems beyond the throttle setting; specifically, the crew's training on new cockpit software, said Bill Fowler, the board's lead investigator.
The software known as the Boeing Laptop Tool, or BLT, calculates the proper speed and thrust of the plane based on information the crew inputs on weight, runway length and weather conditions.
Mr. Fowler said the software was set for the plane's weight at its previous takeoff in Hartford, Conn., almost 110,000 kilograms lighter than the Halifax load.
After interviewing airline staff, the board concluded the software training process was incomplete.
"The company undertook to implement this [software] package following guidance material," Mr. Fowler said. "The question arose: Did they do it adequately? In our view, not all of it."
Mr. Fowler said the software could allow crew who were unfamiliar with the program to use the previous takeoff's weight data.
The investigator declined to elaborate further, saying the full analysis will become public when the board's final report is published in several months.
When asked about the crew's training in an interview, company spokesman Steve Anderson said it was adequate. He also disagreed with the investigators' concerns about pilot fatigue.
"They'd had sufficient rest at different stages of the journey. It's as simple as that. We don't believe it played a role in the accident."
At the time of the crash, the crew had been on duty for 19 hours. The full trip would have been 30 hours, Mr. Fowler said.
In Canada, regulations allow a similar-sized crew a maximum duty period of 20 hours. In the United States and England, the maximum is 18 hours. But as the plane was registered in Ghana, it wasn't required to follow those standards.
-----------------------------------------------------------------------------------
Rockhound

[filejw]

19 hrs on duty and not fatigued? People like Mr Anderson shouldn't be allowed to run an airline.

[barit1]

The world of commercial aviation is built on operational redundancy: two pilots, two donks (or more), multi-redundant nav, pressurization, everything essential to safety.

Except:

Takeoff planning includes a choice of thrust settings (fixed derate, FLEX, full rated...) predicated on runway, ambient, and TOGW variables. Everythings fine if the raw data are correct and the sums are worked properly and the brakes aren't dragging and you don't have a flat...

My lunchbunch colleague B-52 driver told me they always used (in the 50s-60s) an acceleration check - a time limit from 70 to 120kt I believe. If the time limit is reached before 120 is seen, it's a reject.

There are smarter ways to do this in 2005, but the principle is the same. It would provide a measure of operational redundancy where now there is none.

[FlexibleResponse]

When asked about the crew's training in an interview, company spokesman Steve Anderson said it was adequate. He also disagreed with the investigators' concerns about pilot fatigue.
"They'd had sufficient rest at different stages of the journey. It's as simple as that. We don't believe it played a role in the accident."
At the time of the crash, the crew had been on duty for 19 hours. The full trip would have been 30 hours, Mr. Fowler said.

Anderson states that as his pilots killed themselves after only 19 hours into a rostered 30 duty, it doesn’t count as fatigue-related.

One is led to speculate that if they had instead killed themselves on landing after 30 hours of duty that Anderson would also claim likewise that it would not qualify as been fatigue-related?

It would be a great shame for the aviation community not to learn the salient lessons from this accident and the tragic waste of human life in just attributing it to “Poor Training” and which might merely be corrected by the operator entering the following amendment into the Ops Manual:

“Don’t forget to input the new takeoff data into the computer; otherwise it will default to the last entered data for the previous takeoff”.

If you scratch the surface of any airline that rosters 30-hour duty periods you will find a lot of dirt under your fingernails.

[DOVES]

barit1 wrote:

--------------------------------------------------------------------------------
My lunchbunch colleague B-52 driver told me they always used (in the 50s-60s) an acceleration check - a time limit from 70 to 120kt I believe. If the time limit is reached before 120 is seen, it's a reject.
--------------------------------------------------------------------------------
Why don't you give a look to this:

http://www.pprune.com/forums/showthread.php?s=&postid=1597375#post1597375


Fly safe
DOVES

[Woomera]

barit1

Sadly what was once a routine part of the TO calcs and sentinels, no longer seems to be so

Still as a passenger, apart from paying attention to the safety brief I am in the habit of keeping track of the time from TO thrust applied to rotation.

For most of the places I travel, 30 seconds seems to work, although of course Denver on a hot day and suchlike take forever. No panic just a heightened sense of awareness if it goes on longer than it should.

In the cockpit 'nother story, no data available, except my internal clock and personal kidney cramp alarm system, which is surprisingly accurate.

It has picked up two possibly disastrous events that were not in the least bit obvious to anyone, before they could become a serious issue.:uhoh:

[r3500vdp]

Didn't take very long for the lawsuit to be filed. Except from an article in the "The Brandon Sun" newspaper.

"HALIFAX (CP) - A multimillion-dollar lawsuit has been launched against a British-based cargo airline by the families of crew killed in a fiery crash in Halifax one year ago. Seven crew members died in the MK Airlines crash on Oct. 14, after the heavily loaded jumbo jet failed to gain sufficient altitude, struck its tail on a berm at the end of a runway and crashed into nearby woodlands."

Full article: http://www.brandonsun.com/story.php?story_id=6770

[MarkD]

r3500

compared to the AF358 lawsuits its positively lead footed...

[Flying Mech]

How much is R3500 in USD/€?. No money is worth the price of a human life. May all 7 crew RIP. May Mr Anderson & associates get their just desserts either in this life or the next.

[Maurice Chavez]

3500 rand is about 520$ USD....

[skiesfull]

Flight International 18 Oct '05 has an article blaming inadequate training and fatigue for the crash. The interim findings of the TSB Canada, focusses on the introduction of the Boeing Lap-top and long duty hours as the likely principal factors of the accident. Both have been refuted by an MK Airlines spokesman (as Mandy Rice-Davies said so memorably many years ago "well he would say that wouldn't he?").
This accident came hot on the heels of an SIA 747-400 which also started its' take-off run with power settings and take-off safety speeds set for a TOW more than 100 tonnes below actual weight. In both cases, neither crew realised the significance of the lower than expected performance figures, nor did they call for or set maximum power when it was realised that all was not well. Both resulted in tailscrapes, sadly for the MK crew there was insufficient runway left to achieve lift-off.
We are all aware of approach and landing accidents and the recent efforts to highlight the need for stable approaches and touchdowns commensurate with the prevailing conditions; also there has been much comment on taxiway and runway incursions, with the need to be extra vigilant.
But what about highlighting the need for cross-checking the departure phase? How many of us know the approximate power settings and speeds for a heavy take-off and for a light take-off? In the case of the two 747 accidents, both errors resulted in a V2 discrepancy of about 30 knots.
Perhaps the legacy of the loss of the seven MK crew might be to re-emphasise the need to make our own last-minute cross-check of the runway in use, its' conditions, the flap set for take-off and the power/speeds as expected for the weight. Experience on type certainly helps, as can a clip-board or card memo with relevant figures as a guide. Safety is enhanced by learning from our own mistakes as well as those of others.

[Willit Run]

747 classics, flap 10, 100,000 lbs error equates to 15 knots. I have taken the time to memorize a few numbers, because we use this new fangled computer program to figure out all our speeds, and like any computer; $hit in,$hit out! I don't want what happened to them to happen to me. The old charts worked for many years, and they will continue to be my backup.
I was an engineer for many years, and the 100,000 lb mistake is a common and classic mistake. I encourage pilots to memorize a few max weight numbers, and ask yourself; does this look reasonable?

[Farty Flaps]

The answer is in the first sentence of the post by skiesfull.
Oh and a flag of convenience so only lip service need be paid to industry safety/training/crm conventions. AND IN GENERAL IN THIS OUFIT ,for icing on the cake have an ex mil captain and a f/o who will do anything to get off a bush twin otter straight onto a 747 with no experince of a real airline culture. Back this with a squadron closed shop mentality Result a cockpit gradient that eddie the eagle would be happy to ski down. Et voila, the cake is ready.

[zerozero]

Actually, I'd submit the answer is in the last sentence by Willit Run.

Anyone remember Tom Cook from Southern and Atlas?

When I flew with him he'd make a game out of guessing the V2 speed and the Stab Trim Setting.

I'll be damned if he couldn't guess it within one knot and one tenth of a unit on every flight just by looking at the weight and CG.

Like the man said, look at it and ask yourself, does it look reasonable?

Thanks for teaching me the game, Tom.

[Shore Guy]

Anyone have the link for the full preliminary? Not have any luck finding it.....

[Smurfjet]

Canadian TSB released its report (http://www.tsb.gc.ca/en/reports/air/2004/a04h0004/a04h0004_index.asp)
Gatineau - The fatal crash of an MK Airlines Limited freight transport plane at Halifax International Airport, Nova Scotia, underscores the need for better systems to ensure correct take-off speed and thrust, the Transportation Safety Board of Canada (TSB) said in its final report (A04H0004) released today.
The report concluded that the speed and thrust settings selected by the crew members in preparation for their October 14, 2004 flight to Spain were incorrect for the weight of the Boeing 747-244SF, a converted jumbo jet. The aircraft did not achieve sufficient altitude, hit a berm at the end of the runway, crashed into the adjacent forest, and burned. All seven crew members died.
The investigation found that the crew did not receive adequate training on the Boeing Laptop Tool, a computer program used to calculate the take-off velocity and power necessary in light of factors such as fuel weight, payload, and environmental conditions. TSB investigators found that crew fatigue and a dark take-off environment may have compounded the likelihood of error. As a consequence, the Board called on Canadian and international regulatory authorities to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely.
The Board recommended that: The Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance.
"We are asking the world's regulatory agencies to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely," said TSB Acting Chair Wendy Tadros. "Our investigation uncovered the causes and contributing factors. We now need to work to ensure that this type of accident doesn't happen again."

[lead zeppelin]

From the Globe and Mail

http://www.theglobeandmail.com/servlet/story/RTGAM.20060629.wplane0629/BNStory/National/home

[ExSimGuy]

(from the above newspaper link)Dave Wilson, a spokesman for the company, insisted the training on the takeoff software was sufficient.
"When we took the (software) we actually asked the manufacturer for guidance and we unilaterally developed a self-study training program, which included a 46-page guide for flight crews," he said.

I guess the crews were expected to do this during their rest time between flights :yuk:

I've read almost all this thread and, if they were a pax arline, I'd certainly not want to fly with them!

[keel beam]

Some more from The Globe and MAil

"A news release from MK Airlines says the report's findings cannot be regarded as conclusive because there was no cockpit voice recording of the pilots and first officers final words."

and

"Dave Wilson, a spokesman for the company. Mr. Wilson responded that when at the point of the crash, "they (the crew) were within their time limits at the time.""

and

"The report noted that at the time of the accident, the crew had been on duty for 24 hours, the maximum allowed under MK's own operating manual."

Seems like a bit of pedantic management wriggling to me.

[Shore Guy]

Full Report:
http://www.tsb.gc.ca/en/reports/air/2004/A04H0004/a04H0004.pdf

[Globaliser]

Thanks, Shore Guy. I'd been fruitlessly searching the site for that file! (My own incompetence, no doubt.)

[Shore Guy]

Globiser and all,

No, the TSB doesn't make it easy to find......

Truly a sad story and condolences to friends and family of those involved....fatigue is such an insideous killer.

[Few Cloudy]

It took over 30 minutes to read that but the sense of foreboding increased all the way.

It is yet another warning that everything must be got right, to go flying.

It is perhaps the most convincing documentation yet of the need for wide awake crews and management that understands this.

It must have been terrible.

RIP.

[Rollingthunder]

The TSB is one of our better government agencies.

The list is not long.

[Rockhound]

The final accident report, as usual, makes fascinating - and sobering - reading. A topic was raised on this thread around 27 Nov 2004 and continued for ca. two weeks concerning the origin of the ground markings (scars) between the end of the runway and the berm, and beyond. Were they created by impact of the fuselage and/or the tires? Did the MK aircraft actually become airborne before reaching the berm? Interestingly, the TSB report states:
A scrape mark [made by contact of the aft fuselage with the ground] began 412 feet from the end of the runway...continued through the paved runway overrun area and across the grassy area...[and] disappeared at a point approximately 315 feet before the berm, indicating that the aircraft became airborne. The only indication of aircraft contact with the ground was the ground scar caused by the lower aft fuselage. There was no indication that the tires contacted the ground beyond the paved surface. Fuselage structure...was found embedded in the berm.
The report goes on to state that the only tire marks found in the area of the berm were on broken pieces of the ILS antenna that was fixed on the berm. "No similar marks were observed across the concrete pad on top of the berm, indicating that the tires were above the concrete pad as the aircraft passed over it".
Quite a few of us discussants have been proved way off the mark on these issues.
Excuse me while I finish this rather tired-looking morsel of crow...
Rockhound :O:O:O

[broadreach]

Rockhound,
Leave some of that crow for me will you.
Broadreach

[ExSimGuy]

Still only just over half way through the report. I think I get the implications as I "skipped" to the findings.

As usual, it seems to be a "chain of errors" (and I'm currently feasting on a bit of crow pie after my hasty comment earlier about the airline, although IMHO they received, and deserved, some of the blame)

My gut reaction is sadness and helplessness that these guys were lost when, had the locator antennas been on higher frangible masts, instead of a very solid earth and concrete berm, they would probably have "got away with it" and lived to fly another day (and "lesons learned"). Sad enough that 7 crew perished - had it been a passenger flight, the deaths would have been in the hundreds. For a few bob, the airport could have made things much more survivable for take-off problems or landing over-runs:(

[makintw]

[COLOR=#0000ff]My gut reaction is sadness and helplessness that these guys were lost when, had the locator antennas been on higher frangible masts, instead of a very solid earth and concrete berm, they would probably have "got away with it" and lived to fly another day (and "lesons learned"). Sad enough that 7 crew perished - had it been a passenger flight, the deaths would have been in the hundreds. For a few bob, the airport could have made things much more survivable for take-off problems or landing over-runs:(
Can't agree more, "if only".
Similar to the SQ crash in TPE - if only there had been a physical barrier to prevent the 747 from lining up on the closed runway
mak

[Kalium Chloride]

Just my opinion but looks like MK's PR is gently trying to distribute the blame; a spokesman, following the release of the report, described the conclusions about crew error as "speculation" (because of the lack of any CVR data) - and made a big effort to point out that someone was daft enough to put a soddin great berm in the way, and if it hadn't been there then the 747 might have got away with it.


"The lack of any data from the cockpit voice recorder meant the investigation would always contain a significant element of conjecture to ascertain precisely what went wrong. So sadly we can never be absolutely certain about the exact cause of a tragic accident in which we lost seven fine airmen, colleagues and great friends.

"In the absence of conclusive findings we conducted a comprehensive, proactive review of our operation to ensure that we meet the highest safety standards." - MK Airlines

[Dave Gittins]

Very very sad and like almost all such major disasters a combination of things that have ben building up ... sometimes over years just waiting to come together all at once. And how tragic that a couple of seconds early crew reaction or a lower berm would have made such a difference.
I spent late Friday night reading the report with a deepening sense of forboding as I went through it.
One question comes to my inexperienced mind and I ask this as a simple Cherokee driver who has no experience of heavy metal.
Whatever the computed take off figure given, does not something in the experienced 747 pilots mind say that if a lightly loaded 747 rotated at 130 knots then that cannot be the same figure for a heavily loaded one ? What we all call a gross error check but one the brain carries our automatically.
Wouldn't the incorrect bug speeds and low EPR number have stuck out like a sore thumb?
Or are we simply being told that this was the insidious efect that fatigue had - a lack of "alertness".

[411A]

Quite frankly Dave, fatigue is often used as a convenient excuse for crews that fail to apply common sense, and actually watch what the hell they are doing.
I have seen the young inexpereinced as well as older guys fail to notice what the numbers are for various weights, and apply what you have called a gross error check.
This is especially apparent with FMS/FMC equipped aircraft...crew members look at the numbers, and accept them at face value, even though they couldn't possibly be right....forgeting the garbage in/garbage out principle.

Does fatigue play a factor?
Yes, sometimes...but I believe more often it is simply carelessness.

Example.

A well rested crew, beginning a long range flight, planned at max weight.
The Flight Engineer hands up the takeoff data card, which shows the correct loadsheet weight alright, but the V speeds selected are woefully short of whats required, and likewise with the thrust selected.
I handed the card back to the Flight Engineer and mentioned...you don't really believe this, do you?
He looks at it for about three seconds and says...'ah, well....No, opps, sorry Captain, wrong page.'
Precisely why the data should be closly checked by at least two folks.

FD crew should always be prepared to ask...does this look REASONABLE, and if not, do something about it, pronto.

[Rockhound]

Re KCl's post: Well, MK Airlines would say that, wouldn't they? It's no less reprehensible of them, however, to do so.
Re ExSimGuy and Makintw's posts: One should not lose sight of the fact that the berm did not cause the accident. Of course, it's a given that the area of a runway should be as free of obstructions as possible. The runway closure at TPE at the time of SQ006 was recent and temporary but, at the end of the day, even that cannot be used as an excuse for the actions of the SQ crew. The berm at YHZ was legal and a permanent fixture. In the event, say, of a catastrophic engine failure on takeoff, perhaps the presence of the berm would prevent a successful climb-out. In the case of the MKA accident, a fully airworthy aircraft was being operated in an unsafe manner. The reason for that is the crux of this tragedy.
Rockhound

[RESA]

I am disappointed that two-years later . . . the berms still exist at either end of this CAT-II runway. The ANS-provider has in fact installed similar berms at other airports in the country (identified in the TSB report). Apparently, the service provider continues to be unable to reconcile the cost of frangible structures and bases, versus the cheaper immovable objects. While it is only remotely possible that these structures could ever be the root-cause of an accident . . . guaranteed, they will be a topic for debate in future incidents.

[ExSimGuy]

does this look REASONABLE
some 30 years later, I can still remember (roughly) what EPR corresponded with heavy&short or light&long. Mostly did it by experience (of course, an error and an over-run did not kill me at Cranebank "Airport"!)
One should not lose sight of the fact that the berm did not cause the accident.
of course not, but if it hadn't been there (cost factor - "the cost of safety is only high until you see the cost of the lack of it"), the accident could maybe not have had the disastrous consequences that it did (and future accidents could be far more survivable!!)
a couple of seconds early crew reaction or a lower berm would have made such a difference
"Fortunately" that is usually the case - one malfunction (mechanical, crew, support, company) doesn't often cause and accident - if it did I wouldn't get on an aircraft! Sadly, sometimes all these things get together to bite you. All the industry can do is to try to eliminate as many as possible of the factors so that the "chain" does not get built up.

To that unlucky crew - "God be with you - rest in peace, hopefully your lives wil have been lost to save others - if we learn"

[Rockhound]

ExSimGuy,
With respect, I beg to differ. The berm is a total red herring wrt this accident, except in that it helped to explain how the aircraft broke up.
If one follows your line of reasoning to its logical conclusion, one would have to conclude that, for example:
a. TPE, at the time of SQ006, when it was dark and the weather was bad, should have been closed to all traffic, because someone might have used the closed runway for takeoff or landing.
b. Tenerife airport, at the time of the KLM-Pan Am collision in 1977 when it was fogged in, should have been closed and no ground movements permitted, to prevent a collision.
c. No takeoffs or landings at any time, on any runway should have been allowed at YHZ while the berm was in place, as the possibility existed of an aircraft colliding with the berm. (If then you say the berm should never have been built in the first place, I couldn't argue with that. But how far do you take this no-obstacle-at-any-cost policy?).
Rockhound

[DownIn3Green]

Right on Rockhound...

I've lucky more times than I can count in my measly 54 hours shy of 10,000...

A perfect example would be the time when I as an "experienced" Captain (over 4,000 hrs command on type at the time) departed a Southern US airport in a max gross 727 on a hot day...all three engines over-temped on take-off, but not until after V1/Vr...

What goes through the mind then? Fuel leak and fire on all 3?...bleed leaks on all three?...or something else?...You have just seconds to decide....try to stop and run off the end, or go up and lose everything?...

I decided in those few seconds that it was an "indication error" and continued, because I didn't want to believe it...(and we were past V1)

As it turned out I fried those JT-8D's because all [B]THREE[B]of us upfront didn't notice we commenced takeoff with the engine heat on on a 95 degree day...

If it doesn't look right, it probally isn't right...I should have aborted (even after V1) but on this occasion I got lucky....

However, not wanting to misplace the responsibility here, the slimy F/O immediately went to the CP to report the incident when we got back to domicile, not knowing I had all ready done so 2 days earlier...

Lessons learned...all the way around...

[Bartholomew]

Rockhound..."The berm is a total red herring wrt this accident"

411A..."fatigue is often used as a convenient excuse for crews that fail to apply common sense, and actually watch what the hell they are doing"

And to all the other statements along these lines....

Fatigue was definitely a factor in this accident (imho). Anyone who disagrees should do the proverbial "sit in a dark closet with the vacuum-cleaner on" test for 19 hours and see how they fair with an average SAT test (or something similiar!)

Inadequate training on the performance computer definitely played a large part in this accident.

The berm definitely had something to do with the terrible demise of the crew and the aircraft.

How many other airfields are there in the world which have a large solid berm at the beginning/end of the runway? Not having been to too many myself, but I would hazard a guess that most pilots in the world would like to know this little pertinent piece of information (on the Jepp plate for instance) should there be one at the airfield at which they are operating into/ out of?

I'm not trying to suggest that the other factors should be ignored, but considering a quote from one of the links posted previously...

http://www.emediawire.com/releases/2005/4/emw233476.htm

"...On Wednesday 12 March 2003, at 1547, flight SQ286, a Boeing 747-412 registered 9V-SMT, started its take off at Auckland International Airport for a direct 9 hour flight to Singapore. On board were 369 passengers, 17 cabin crew and 3 pilots.

When the captain rotated the aeroplane for lift off the tail struck the runway and scraped for some 490 metres until the aeroplane became airborne. The tail strike occurred because the rotation speed was 33 knots less than the 163 knots required for the aeroplane weight.

The rotation speed had been mistakenly calculated for an aeroplane weighing 100 tonnes less than the actual weight of 9V SMT. The 389 persons on board had a very lucky escape. This aircraft did not crash mainly because there was no berm at the end of the runway..."

Unless I'm mistaken, there have been numerous similiar incidents at other airfields scattered around the globe, including two at Jnb? (An SAA 747-400 and an Emirates Airbus??? Please correct me if I'm wrong).(I do realise that incorrect (lower) thrust equates to incorrect (higher) weight... in these circumstances).

I just hope that we can all learn from what happened to those poor 7 souls in Halifax, and maybe be less critical and more constructive towards creating a safer environment for us all to work and play in.

With respect, in their memory....

"Captain Mike Thornycroft

Captain David Lamb

First Officer Gary Keogh

Flight Engineer Pete Launder

Flight Engineer Steve Hooper

Loadmaster Chris Strydom

Ground Engineer Mario Zahn

R.I.P."

css
--------------------------------------------------------------------------
The Grass Isn't Always Greener Over There...

[Dave Gittins]

I would not doubt that fatigue plays some part - but I ask the same question again (I strongly make the point of being a lowly Cherokee driver who rotates about 65 knots whatever) that surely as a highly experienced heavy metal driver something in the brain screams "that cannot be right" if you have a computed take off speed of 130 knots for a heavily loaded machine whose take off speed needs to be 165 knots.
At what point does fatigue overcome aviators instinct and a captains thousands of hours of experience ???
Surely if somebody had been alert enough to recognise the incorrect speeds, the berm would never have come into it.

[Bartholomew]

Have you tried the hoover test yet? It varies with the individual, but tiredness is silent and deadly... ask anyone who's seen the black dog.....

Please keep this one thought in mind....

There are 4 probable times when you are most likley to kill yourself in aviation..

When you are released into the training area alone after your first 5 hrs solo..

When you get your first 100 hrs..

When you get your first 1000 hrs..

When ever you've done something a thousand times before, and you are tired...(and this applies to all aspects of life... tiredness kills.... and big dirt hills in your path certainly don't help!!!!)

You should only grade yourself on your worst performance in an aircraft... this is what people will remember. (a greaser is easily forgotten... a thumper (for whatever reason) will be immortal)

Just learn to read through the proverbial which you find in these threads, and hear in your flying club, and hang on to the important stuff which will save you one day and bin the rest... don't over-analyse everything you read/hear... big heavy-metal drivers are not infallible... experience certainly helps most of the time... but in this case all the holes in the cheeses lined up at the wrong time.

Keep the blue side up Dave......it is possible to survive a blind date with destiny!

[Trash Hauler]

Bartholemew is correct regarding fatigue. It is insideous and quite surprising what your mind will allow when heavily fatigued. That the crew did not recognise their error until too late is sad and maybe surprising to some however I have made some mistakes suffering under the effects of fatigue that I could not believe at the time. In one instance I put fuel in a tank that was snagged for a leak and MELed to home base. This was not picked up by anyone else on the crew and I first realised it at top of climb.

Dave Gittins

With the wide weight range that is possible with large transport aircraft V speeds can vary by 30 knots. If the Vr speed was within the range that could be experienced in a light weight B747 it is possible, given the fatigue, that no alarm bells rang in the minds of the crew.

[TheSailor]

Hello,

Just a "anecdote" to proof..the fatigue is a factor of senseless errors.
One day (quiet sea ..full visibility) a supply ship stuck at good speed in a pontoon of our drilling rig....
No human casualties..thank's god.
In the examination who follow....the supply ship captain testimony he was sure (in his head) he was manoeuvring the engines control lever as he approach the rig...but in fact..due to his enormous fatigue (no sleep from 28 hours due to the fear of the first deck officer incompetency)..his body no react at his brain orders...
So...I believe the fatigue factor is one of importance.

Regards.

[Rockhound]

Bartholomew,
We all know the berm had something to do with the accident but it had nothing to do with the cause[I] of the accident. The berm was legal under regulations as they presently stand at YHZ. You appear to consider it an unacceptable hazard and if so it seems to me that logic would require that, were you in charge at YHZ, you would have kept the airport closed to all traffic until the berm was removed. My question was, would this restriction be reasonable? The question is certainly open to debate.
It appears that the accident was caused by straight pilot error. IMHO the focus should be on [I]why the pilot error was committed and the appropriate lessons learnt.
Rockhound

[Bartholomew]

"We all know the berm had something to do with the accident but it had nothing to do with the [i]cause[i] of the accident."

Interesting..

(Here I go opening myself up to all sorts of abuse...)

If the berm wasn't there, would they have impacted Mother Earth?

With SQ286..." This aircraft did not crash mainly because there was no berm at the end of the runway..."

Considering the other 2 incidents in Jnb which I've previously mentioned, would they have had the same result if they had had to climb over a big earthen berm?

I am not trying to come to a conclusion as to the fault cause of the crash (the holes in the cheese did that already).... but consider if, in this case, the big earthen berm hadn't been there?


"RA indicated 36' prior to impact"

How many other incidents around the world haven't been recorded because there wasn't a big fat lump of dirt sitting at the end of the runway?

I might be wrong, but even after everything else that had gone wrong, these guys did their absolute best to get their beast into the air... and they would have succeeded..... but for the berm. Read through the other reports of the incidents I've mentioned, I don't think they would've got away with it in the same scenario?(should the berm have been there instead?)

Besides all else... these poor guys DID get their plane airborne... and SHOULD have climbed away... shaken and stirred, and probably would've dumped and returned to an investigation and a ****ting on, but would still be around to share a Scotch and a very illuminating story... BUT FOR THE BERM!

YES YES YES... I would close YHZ and every single other airport in the world who deem it necessary to place a BIG UGLY UNNECESSARY MOUND OF DIRT in the way of my aircraft which one day I might be trying to get itself into the air!!!

I don't think I'm alone in my thinking.....

If I am, then every other airport in the world should feel safe in putting a 50' block of flats at the end of every other runway which exists in the world? ,(Heathrow, Gatwick, JFK etc) If I am wrong, then please correct me?

If, like me, you feel that airports should be left obstruction free (within reason) please write in to this thread and help me out.

Rockhound... I'm not trying to pick a fight, all I'm asking is that you see reason in my explanation...they wouldn't have been there if they were doing things another way, or had more thrust or.... but.... at the end of it all... these poor guys saw the end of the runway coming, jammed up to radar thrust, dragged the poor girl off the floor on her arse, got her into the air.... and ran into a big lump of Canadian earth.

Fair?

I don't think so.

[RESA]

I think my previous statement is correct; “While it is only remotely possible that these structures could ever be the root-cause of an accident . . . guaranteed, they will be a topic for debate in future incidents”

I do however wonder what goes through the mind of a pilot in charge, who has seen (in day-light) what is waiting off the end of the runway . . . hit the binders . . . or give-her-**** !?!

I hope I will never find myself present in this scenario . . .

Optimistically, we can all do what we can to eliminate these “No-Win” decisions ??????

[Rockhound]

Bartholomew,
I quite understand what you're saying. Of course it was an unspeakable tragedy that the MK crew had to pay for their mistake with their lives. You readily confirm that, were you in charge, you would keep YHZ closed until the berm was removed. You have the courage of your convictions and I salute you for that. Personally, I think you're overreacting but that's just my opinion and I'm no expert, just an interested observer. If your policy were to hold sway, I'll bet a whole string of fields would have to be shut down and operations curtailed at many more.
You make a plea for airports to be obstruction-free but add a qualifier: "within reason". Ah, that's the rub. What exactly constitutes a reasonable obstruction? I guess on the matter of the YHZ berm, the top of which was at the same elevation as the end of the runway (because of the sloping terrain), we disagree.
Rockhound

[DownIn3Green]

Yo, Bart,

Let your Chief Pilot know your feelings and you may just get your wish...no more flying for you until every airport in the world can protect you from yourself...:=

[jumbodrvr7]

This argument about the berm seems to have become very polarised.
As someone who knew all the crew allow me to give my (hopefully unbiased) take.

1) Of course the berm did not cause the accident, human error did that.

2) Mere compliance with the regulations does not necesarily make the presence of the berm acceptable. The investigators of this accident clearly believe the berm played a role. From page 77, para 4.3.1:

"The Board is concerned that, because man-made objects, such as the berms off the ends of runways 06 and 24 at Halifax International Airport, are not evaluated in terms of their potential risk to aircraft landing or taking off, there is the potential that an unnecessary hazard may be allowed to exist when mitigation for such risk may be reasonably undertaken."

The way I read this is that the YHZ airport authority chose to take what used to be a long and clear over-run area, and spoiled it by placing an earthen berm on it, when there were other options available which could have achieved their aims and maintained a nice clear over-run.

That is not to say that any airport with such obstacles is automatically unsafe, just that it is a bit silly to place an obstacle where there is a remote possibility of it playing a part in an accident, when other options exist.

[anartificialhorizon]

As with most accidents there is a primary cause of loss (crew fatigue in this case) with the berm being a secondary factor which ultimately caused the unfortunate demise of the crew.

As with the other recent high profile loss in Canada ( Air France A340 overun ) at Toronto the fact that there was a large gully at the end of the active did not cause the accident, but was a factor in the destruction of the aircraft. Very luckily there were no deaths.........

Safety in Aviation is all about mitigating potential dangers and therefore whilst hazards at airports such as the berm and the gully exist in close proximity to the runways, incidents such as this will continue to happen. Whilst it is always going to be a possibility that an aircraft could overun, slide off the the side of a runway, land short or indeed for whatever reason get off the deck late, the chances of getting away with the incident should be made as great as possible by ensuring proper clearway's at both ends of runways and employing as much frangible equipment as possible in close location to the runway.

I am not talking about knocking down blocks of flats a mile from the runway as by this point any impact is likely to be disastrous, but ensuring there is nothing too hard to run into at close quarters to the runway................

simple really...........:ok:

[411A]

>>.....primary cause of loss (crew fatigue in this case)...<<

Nonsense.

The REAL cause was the crew simply were not paying attention to details.
Very similar to the recent C-5 accident.

Minds occupied elsewhere is never a good idea in transpoirt aircraft operations.

More and more I see crews trying to grasp at the 'fatigue' issue, when in actual fact many times they simply do NOT pay attention.
Perhaps they are bored with the job?
If so, these folks should definitely think about another profession.

Good 'ole Harry Truman said it best, many years ago...

'Can't stand the heat, stay OUT of the kitchen'.


True then, true just as well today.

[Rockhound]

411A,
You may well be right but we should not discount the possibility (probability?) that fatigue promoted the MK crew's inattention As I've said before, the crux of the isssue, it seems to me, is why was the pilot error committed?As you point out, the C-5 accident also resulted from inattention by the crew but fatigue does not seem to have played a part. This suggests to me that every accident is different and we should be careful to examine each one individually.
Rockhound

[GlueBall]

Mr "MK" should go to jail for scheduling his crews to be on duty 20+ hours. Nuff said.

Sensible regulations should be rewritten to stipulate that any scheduled flight time exceeding 8 hours in a 14 hour period per calendar day can only be operated nonstop and with an augmented or extra crew; no multi-stop sectors exceeding 8 hours scheduled flight time should ever be allowed.

[ShotOne]

I am surprised to see the "berm" issue has come up again after all this time. Had this accident happened at some of MK's other destinations, the overrun would have been even less forgiving. Would we now be blaming the shopping centre or apartment blocks as opposed to the berm??

[fantom]

Mr "MK" should go to jail for scheduling his crews to be on duty 20+ hours. Nuff said.
I take it, Sir,or Madam, you have sufficient evidence to support your case in court. Needless to add, you will have ample funds to pay damages and costs, if awarded against you.
I respectfully remind you: your assumed anonymity is not assured on a public site such as as this.
I have no connection whatever with any organisation here mentioned.
Just trying to be helpful...

[the_hawk]

You've been helpful indeed fantom - in making me laugh :D

[Mad (Flt) Scientist]

I am not talking about knocking down blocks of flats a mile from the runway as by this point any impact is likely to be disastrous, but ensuring there is nothing too hard to run into at close quarters to the runway................
simple really...........:ok:

One problem might be that there are often things around on airports which, if hit by an aircraft departing its runway, would not only cause the likely loss of the errant aircraft and passengers/crew, but would ALSO cause the loss of the passengers and crew aboard that SECOND AIRCRAFT. By which Im alluding to the relatively small separations between taxiways and runways; if one is to worry about overrun areas past any allowed stopway, one should also logically worry about departures off the side of the runway. If you start to impose restrictions forwards outside the accel-stop allowances, why not sideways?

As an example, when we are conducting Vmcg type testing, our lateral safety distance allowance usually means that the ground support personnel cannot park on the parallel taxiway because they are in the 'danger zone' - if we're worried about hitting a pickup truck, we certainly should worry about an airliner. Now, in theory, once Vmcg is known and speeds are scheduled accordingly, no-one should be going anywhere near the adjacent taxiway; but the same logic says you shouldn't be overrunning either ....

[GlueBall]

fantom: "...I take it, Sir,or Madam, you have sufficient evidence to support your case in court...."

The evidence is in the public domain, sir, ...puplished by TSB Canada:
"at the time of the accident the crew had been on duty 19 hours!" :rolleyes:

[MrBernoulli]

GlueBall,



Will you be calling for the heads of the JAR authorities as well? After all, they allowed the following (quote from the Halifax accident report):

"Italy . After the accident, an Italian-registered company was found to have an approved duty time limitation scheme with a maximum allowable duty period for an augmented crew, consisting of three pilots (in an aircraft equipped with an inertial navigation system), of 24 hours and a maximum of six sectors."

Note the use of the word APPROVED!



Snarfel,

MK are very deep into being audited by the CAA for a UK AOC. I was under the distinct impression, from colleagues in MK, that this would likely be granted this summer (2006).