kenya airlines 737-800 missing

[barit1]

Typical eyewitness account (after a midair):

I think the most amazing thing was the fact that sitting on top of all that wreckage was a manual, and I think that whoever was in that plane was looking to see what he could do at the last minute

Yeah sure... :rolleyes:

[MungoP]

lomapaseo I'm not a fan of "what if" news articles any more than "drivel"

How many B737 size planes have been knocked out of the air on takeoff into weather ?

For anybody out there that has not had first-hand experience of a full blown Tropical storm system in the rainy season... hear now..that an aircraft of ANY size getting too close to the cell..and sometimes the gaps between them are almost indistinguishable... will suffer turbulence beyong your worst imaginings.. 20 miles away will give you a very nasty experience.

[vapilot2004]

After reading the allafrica link, I thought a posting of all statements released by Jim Proulx of BCA regarding Kenya Airways flight 507 thus far would be helpful.


Boeing spokesman Jim Proulx said the plane that crashed was equipped with an emergency transmitter that sends out an automatic locator signal "in the event of a rapid change in velocity."

Proulx told The Associated Press by telephone from Seattle that the transmitter would have been activated upon impact and can also be manually turned on by the plane's flight crew.

Proulx said there have not been any safety concerns with Chicago-based Boeing's fleet of 737-800s. About 2,000 737-800s are in use around the world.

"We express our profound concern for the passengers and crew on board on the Kenya Airways flight that went missing," Proulx said Saturday. "We stand ready to assist the authorities if they ask us to do so." - AP and Reuters.

[His dudeness]

How many B737 size planes have been knocked out of the air on takeoff into weather ?

The PANAM 727:
9 July 1982; Pan Am 727-200; New Orleans, LA: The aircraft was on a scheduled flight from New Orleans to Las Vegas and crashed shortly after takeoff due to wind shear. All seven crew members and 138 passengers were killed. Eight people on the ground were also killed.

for example...and DELTA 191...

[ChristiaanJ]

Boeing spokesman Jim Proulx said the plane that crashed was equipped with an emergency transmitter that sends out an automatic locator signal "in the event of a rapid change in velocity."
Proulx told The Associated Press by telephone from Seattle that the transmitter would have been activated upon impact and can also be manually turned on by the plane's flight crew.
Factually correct. But buried a few meters in mangrove swamp mud, I doubt an ELT transmitting on UHF/VHF (406MHz and/or 121.5MHz) could be received even on-site, leave alone by a satellite.

[RiverCity]

My own experience with VHF and UHF radio gear (not ELT and not aircraft) has been that signals could easily be heard under rather surprising conditions. Perhaps not a satellite --yet you never know-- but but by near-field receivers. A few meters in nonconductive (that is, no metal around it other than debris) muck may equate to a somewhat greater distance in water, and not to be counted out.

[ChristiaanJ]

RiverCity,
Point taken, although from the description of the crash I would have doubted anything would have been detectable even a few hundred meters from the crash site, i.e., from an aircraft literally overhead..
Danny,
If you think this is off-topic, please feel free to move this ELT discussion to TechLog or elsewhere, or tell us to start another topic.

[rmac]

Well said MungoP. Sensible advice, I hope someone out there is reading it and taking it in. Do not f#ck with wet season CB's in the tropics, as has been written earlier in the thread, "they will suck you in and spit you back out in component parts".

[lomapaseo]

How many B737 size planes have been knocked out of the air on takeoff into weather ?

The PANAM 727:
9 July 1982; Pan Am 727-200; New Orleans, LA: The aircraft was on a scheduled flight from New Orleans to Las Vegas and crashed shortly after takeoff due to wind shear. All seven crew members and 138 passengers were killed. Eight people on the ground were also killed.

for example...and DELTA 191...

Thank you that confirms my memory of only one, DL191 was on landing.

Pretty rare occurance at low altitude takeoff considering the fleet total hours, something just a little more common than a meteor strike.

[bomarc]

would you count a massive windshear encounter during a go around as a takeoff or landing? after all, a go around is an airborne takeoff to some?

if it is a takeoff for the purpose of this question, a dc9 in CLT crashed while doing a go around in extreme wx. same time frame as OJ simpson's slow speed chase

[lomapaseo]

I believe the DC9 was caught in the windshear during landing and was unable to climb out. At any rate none of the windshears that I'm familiar with led to a nose into a 15 ft crater.

I'm still waiting for any photos of the wings or engines that might at least give an indication of the attitude of the plane when it hit.

[TheShadow]

It is unclear why the signal was so far off the mark, but it appears the plane's emergency locator beacon's final signal was garbled — indicating a false position.
.
May 11, 2007
.
Kenya Airways 737 Search Satellite Fix was "Red Herring"
.
Cameroon aviation officials are claiming that data offered up by the French Satellite Tracking Centre in Toulouse was misleading as it centered their initial search area 150kms away, roughly along the Kenya Airways 737's planned track. The Communication Minister Ebenezer Njoh Moulle said: "The information they furnished pointed to two areas, one in South Africa and the other in Nyong and Soo (southern Cameroon). That is why the initial search for the plane was directed to Lolodorf and its surroundings, which is about 150 km from the actual crash site," he told reporters in Yaounde. "The question is why the plane's distress signal frequency failed to operate automatically, as ought to be the case," Moulle said.
The explanation would seem to be in two parts. Firstly the Emergency Locator transmitter (ELT) located in the tail of the aircraft would only have emitted a few short bursts before being immersed in the rapidly filling crater. That 406MHZ transmission may have only been picked up by two satellites within Line of Sight of the ELT in its location below the partly shielding crater sides. The brief transmission would produce two line-of-position (LOP) arcs that intersect twice (likely quite geographically dislocated) at very shallow angles (visualize two intersecting circles overlapping by half radius)). If a third satellite cannot produce another confirmatory LOP, the two points of intersection will represent two rough fixes, only one of which will be approximately correct (and therefore chosen). A four satellite ELT fix by contrast will be quite accurate and without any fixing ambiguity....particularly after a brief resolution process based upon continuing transmissions. ELT's below the lips of craters have done this before....however a crash crater that fills rapidly with water provides a new challenge for ELT designers. Perhaps a floating antenna buoy that detaches upon impact? Related Story

[arcniz]

Kenya Airways 737 Search Satellite Fix was "Red Herring"

If wishes were horses....

Current state of the art for solving this problem, at least from a gee-whiz point of view, is "smart dust", consisting of a very large number - (millions plus) of self-powered or solar powered intelligent radio transmitters that can collaborate with each other as a network or work alone, each one not much bigger than a flyspeck. Relatively cheap to have and brainless to deploy.

Released or ejected as a cloud, a partial population of these will survive any sort of accident with high probability, then distribute on the breeze and be readable by satellite, portable, and surface equipment.

Won't do the aircraft passengers and crew much good in a case like this, but such gadgets might shorten the search cycle, if and when deployed.

----

An alternate hypothesis to the (location mystery) position taken by Cameroon authorities is that the location was known and understood by airport officers and others relatively soon after the accident. The proximity of concentrated population areas near the airport and timing of the events in the departure cycle suggests that the belief the site could be 150 km distant from the airport might require a mystical transformation of some sort on the minds of the ATC people and others.

Maybe the airport people were trying to delay the inevitable until someone with appropriate authority could be called into the loop? Or maybe they had concern about looting and site intrusion by the local population before rescue,
investigation, and salvage personnel, etc. could get to the site.

Days have passed and we still have not seen aerial pix of the site disseminated to news channels, although both officials and private parties presumably do have aircraft and cameras at hand, and the trip to the accident site is not a very long one..

Who knew what when is an interesting puzzle in itself.

[kotakota]

I am not aware of the crews planned duty that night but suspect that it was an all-nighter , starting from Abidjan , stopover in Douala , on to Nairobi arriving at dawn , a real red-eye ? Anybody please correct me if I am wrong.

IF this was the case , a BIG IF , and if the aircraft had no faults ,then this may have been a classic case of clock-watching because of FTLs , and the usual dose of get-home-itis. The weather did the rest.
Probably no crew in Douala to take over if limits were exceeded , the flight would have to be postponed / delayed , find hotels for crew and pax , 12 hours delay etc etc ??
This would not be the first time this has occurred and it certainly will not be the last. How many of us have got away with it and thought afterwards 'It is not worth it and I will NEVER do it again ?'
Apologies if my speculations are hurtful - they are not meant to be , just my 2 cents worth. I am ex- Kenya and feel very sad about this episode . KQ have been doing so well in recent years , deservedly so , and nobody deserves this.
Keep your chins up guys.

[BOAC]

This (http://www.eastandard.net/hm_news/news.php?articleid=1143968485) from the Africa Forum gives a possible route for the aircraft after departure.

It appears the CVR had still not been located (12/5).

[Danny]

I think in this case, this "Fairy Dust" is about a better method of signalling where a downed a/c may be located. At least that is my understanding even though the poster was not too clear about the theory.

In this case I'll allow it, even if only theoretical at the moment as it is related to the fact that it was difficult to locate the wreckage initially. :suspect:


If wishes were horses....

Current state of the art for solving this problem, at least from a gee-whiz point of view, is "smart dust", consisting of a very large number - (millions plus) of self-powered or solar powered intelligent radio transmitters that can collaborate with each other as a network or work alone, each one not much bigger than a flyspeck. Relatively cheap to have and brainless to deploy.

Released or ejected as a cloud, a partial population of these will survive any sort of accident with high probability, then distribute on the breeze and be readable by satellite, portable, and surface equipment.

Won't do the aircraft passengers and crew much good in a case like this, but such gadgets might shorten the search cycle, if and when deployed.

[bomarc]

iomapaseo


regarding the dc9: the plane was making a go around and then encountered the microburst/windshear etc.
and yes, no crater.

[threemiles]

an all-nighter , starting from Abidjan , stopover in Douala , on to Nairobi arriving at dawn

it had been mentioned earlier on this thread that the crew did come onboard in Douala

[chuckles1066]

"chuckles- that correspondent you brought up wrote some strange posts with strange ideas. He is Kenyan and doing it in a foreign language."

Then might I respectfully suggest the mods ban him before his words are taken out of context and assumed to be representative of the industry in general?

[ChristiaanJ]

"chuckles- that correspondent you brought up wrote some strange posts with strange ideas. He is Kenyan and doing it in a foreign language."
Then might I respectfully suggest the mods ban him before his words are taken out of context and assumed to be representative of the industry in general?
Might I respectfully suggest that some of the posters here, for whom English is clearly a foreign language, make a much better job of it than some of the "English mother-tongue" posters, who can't be bothered to at least post with approximately correct spelling and grammar (not to mention texto-speak).
(I'm NOT referring to you, chuckles, in hat respect.)
The subject was discussed elsewhere, so let's drop it here.

[arcniz]

Rainboe says:
Can someone please tell me why we are talking about Fairy Dust now?


Surely it must be difficult to be the annointed barking-dog. Those cold spring nights out behind the shed, etc.
I have admired some of your past work, but in this instance must suggest that you have totally lost the plot. The first tip-off is that you felt the need to change the name of the thing in order to mock it. Different names and words often correspond to different things, in people language, and so each needs be regarded for what it is, rather than what barks most neatly. I have occasionally made this mistake myself, so please do not take the thought as harsh criticism.

Should you wish to continue barking, here is a link to where you can roll in 'Fairy Dust' (http://www.efairies.com/clothing_costumes_fairydust.htm)





The relevance of the 'Smart Dust' paradigm to the ELT Inop problem is as follows: Even with crash-resistant design, ELT's are subject to failure in high energy impact situations due to a) the requirement that the ELT remain tethered to the aircraft; b) the need for the ELT to transmit at relatively high power via an antenna which itself needs to "see" the sky, which may be broken off or covered up; c) the ELT is a relatively expensive and cumbersome subsystem requiring regular maintenance, so highly-plural ELT's(to possibly solve a,b) are not very practical, and d) the civil ELT 'guard' frequencies are but two in number for the entire planet, causing the design and use of ELT's to be strongly biased to prevent false triggering that can jam valid signals - but this constraint limits useful effect in some cases.

A 'Smart Dust' approach to augment ELT ops hypothetically could provide a secondary mechanism for locating downed aircraft via sat, ground, aerial, etc searching, which could be a totally passive system when not in use and would require very little systems-integration effort for retrofit to the existing fleet. When triggered by impact or signal, the SDELT would release hundreds or thousands of low-cost, micro-miniature transponders into the nearby environment, with a high probability that some would be in view and able to respond to search means. Because of very low signal power and other technical measures, direct identification would be possible, with false triggering and jamming not a major consideration.

http://www.nanotech-now.com/images/golem-dust-penny-large.jpg

'Smart Dust' is a very modern signal networking and modularity concept (with somewhat unfortunate name) that was articulated, publicised and developed toward commercial reality over the last ten years by Prof. Kris Pister at the University of California Berkeley. Should you wish to be informed, these links may prove helpful:

collaborative Smart Dust project backed by General Electric Corp. (April 2007 press rls) LINK (http://www.dust-inc.com/news/pr/2007_Apr_24.shtml)

Company founded by originator of concept LINK (http://www.dust-inc.com/non-index.shtml)

a broad-brush news treatment about applications LINK (http://www.nanotech-now.com/smartdust.htm)

prototype image -- biig LINK (http://www-bsac.eecs.berkeley.edu/archive/users/warneke-brett/SmartDust/images/GolemDustPenny_small.jpg)



Danny says:
I think in this case, this "Fairy Dust" is about a better method of signalling where a downed a/c may be located.

Good one - got it on the first try, despite my verbal fog. Thank you!

One willl strive to be more clear.

[threemiles]

Given the young age of the Kenya 737-800 it certainly was fully ADS-B transponder equipped and transmitting its GPS ground and flight coordinates every second into the dark African night on 1090 MHz.
A simple ADS-B receiver (commercially available for less than $800 plus a laptop) at Douala airport tower would have recorded its flight path to a text log until it was down, i.e. position coordinates, altitude, ground speed, vertical velocity, true track. A quick view to the text log after radio comm was lost would have led to the event than happened - within minutes rather that days.

[Dogma]

Why have they not found the CVR? Despite the total destruction of the aircraft, it has to be within a very tightly defined area.

This investigation requires the best in the business. So often have African investigations be little more than publication of a vague idea of what might have happened + taking into account of political sensitises. I fly the sister ship of this aircraft regularly - so you might say I have a vested interest in discovering the truth.

Can anyone from Kenya Airways tell us whether you were carrying out the mandatory Spoiler inspection prior to every departure?

[bomarc]

<To quote Cheney, 'you fight with the army that you have, not with the army that you want'. >

Yes, but you win with the army you build .

for example: the US Marine corps prior to Dec 7, 1941 was smaller than the police department of New York city . The Marines grew and helped win the war.

So did all branches of the service. Perhaps that is why the USA is not doing well in Iraq...bush decided to fight the war on the cheap.

I think the smart dust radio information was a fine addition to this thread and shows how things could be improved.

I fully expect you to zap my post, but hope a few people read it and remember it.

[wes_wall]

I think the smart dust radio information was a fine addition to this thread and shows how things could be improved.



I agree. The topic is in keeping and on point with one of the key elements of the incident.

[PaperTiger]

How many B737 size planes have been knocked out of the air on takeoff into weather ?Not on takeoff I grant, but a number have flamed out in thunderstorm/rainstorm conditions, viz:
http://aviation-safety.net/database/dblist.php?Event=ACEP .

[gwillie]

Why have they not found the CVR? Despite the total destruction of the aircraft, it has to be within a very tightly defined area.
Cameroon officials disorganised
...The most important component that is yet to be recovered is the cockpit voice recorder.
Some of the Kenyan officials here and the next of kin have been feeling dejected because of the disharmony with Cameroonian officials..... Equipment that would have speeded up the rescue is also not available. This includes heavy-duty pumps as well as protective gear, which have had to be transported from Kenya.
http://allafrica.com/stories/200705130024.html

[ChristiaanJ]

Where is the 737-800 CVR located? Forward avionics rack or rear fuselage?

[Capt Chambo]

Can anyone from Kenya Airways tell us whether you were carrying out the mandatory Spoiler inspection prior to every departure?
The AD wouldn't have applied to KQ Boeing 737-800. Registration 5Y-KYA c/n35069.
Here is a link to the Boeing AD which includes the aircraft serial numbers that are affected.
http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/d08e486777976e508625729e006ebcde/$FILE/2007-06-52.pdf
CC

[vapilot2004]

Where is the 737-800 CVR located? Forward avionics rack or rear fuselage?
Generally these things are in the aft cabin area forward of the vertical fin attachment point. The CVR includes an ultrasonic underwater pinger and is bright orange just like the DFR. The CVR on this aircraft would also be digital - using memory chips rather than tapes or drums - making it very rugged and reliable.

[hoggsnortrupert]

G Willie: Good post matey, a balanced reporter, a good article.:ok:
Capt Chambo: Thanks, I know I was wondering, as were probably a few others. Good one Matey.:ok:
Chr's
H/Snort.
PS:
Fairy Dust: Can be bought by the Ton from the NZ Govt.:}

[jet_noseover]

Hmm, I was under the impression that the DFDR was already sent to Canada....Apparently, not.

GOVERNMENT SPOKESMAN Alfred Mutua has brought home to us the politics of aircraft accident investigations. Apparently, there had been a bit of a tussle between Kenyan and Cameroon authorities over the custody of the 'Black Box' recovered from the wreckage of the Kenya Airways crash.

Dr Mutua informed us that Kenya preferred that the Black Box be handed over to Canadian Authorities.


And he went to tell us in great detail why. Canada, he said, was a neutral country, unlike Kenya and Cameroon who were both interested parties.

Another alternative, the United States, could also not be considered neutral because it was the home of Boeing, the aircraft manufacturer.

And none of the European countries could be considered neutral either because Europe is the home of Airbus, the main rival of Boeing.

So what is all this talk about neutrality and interested parties and whatnot and yet we are talking abut a fatal plane crash, not ODM-Narc politics?

Dr Mutua did not have to explain all that, but the answer should be obvious.

Cameroon is not a neutral party to the investigation because the crash occurred on its land shortly after the plane left Douala Airport.

Therefore, it must be presumed that the Cameroon authorities might be keen to demonstrate that the crash was no fault of theirs, that it cannot be pinned down to erroneous clearance for take-off in inclement weather, or faulty instrumentation to guide such decisions.

Then we come to Kenya, or Kenya Airways, to be precise. It was their plane that went down. The reputation, and business prospects, of an airline rests on all those things they advertise: Flatter beds, more leg room, friendlier service, superior smiles, on-time arrivals and departures, less unpalatable food, route networks and so on.

And, preferably left unsaid lest customers be reminded about the hazards of flying, the safety record.

The Abidjan disaster of six years ago was seen as an aberration; it happened to one of the safest and best airlines in Africa. Another major crash so soon afterwards is a veritable disaster for KQ's safety record. The last thing the national carrier would want is to be shown at fault for the Douala crash.

Then we come to Boeing. Aircraft salesmen may not be as ubiquitous in every street corner as used-car dealers. But in their rarefied world, they are just as pushy and aggressive.

The duel for global dominance between Boeing of the United States and European Airbus consortium gets as low down and dirty as can be.

If KQ 507 went down because of a manufacturer's defect or a basic flaw in the model, it will be like a punch in the solar plexus for Boeing. That will mean plenty of lost business.

So both are interested parties, and neither they, nor the authorities in their regions of domicile, can be entrusted with the all-important Black Box.

THE WORLD HAS CERTAINLY SUNK low if the investigation of a major plane accident is to be held hostage to political and commercial considerations.

If Dr Mutua's revelation is to be taken to its logical conclusion, then not even Canada is completely neutral. After all, the land of the maple leaf is joined by an umbilical cord to the US. It is also a member of the US-led Nato alliance.

At the same time, however, it is not just, like us, a mere member of the British Commonwealth, but it is still a British dominion. And the country also has a large population which looks to France rather than Britain.

Well, at least both Boeing and Airbus can trust Canada. But who shall we trust to tell us the unvarnished truth?

more at:
http://allafrica.com/stories/200705141602.html?viewall=1

[vapilot2004]

The comments in the article above hint at the amount of corruption (and conversely, lack of trust) that exists in that part of the big marble. This seems to go back to the idea that if someone is unwilling to trust you, it is probably prudent to limit your trust in them.

Dr. Mutua made one good point regarding the FDR: Like anything computerised, it can be fiddled with in a lab to produce lies upon request.

All the same, to imagine that Boeing (or Airbus?) would ever be so devious seems to be bordering on paranoid thinking.

[Frosch]

Remember Strasbourg? Or Mulhouse?

[Whenwe]

You are probably aware of the Helderberg Accident B747 Combi that crashed off the coast of Mauritius almost 20years ago.
That ghost is alive and well on another website and you want to read there to what could have, and probably did have happened to the CVR and other tapes.
Sorry, mod, not my style to go off the thread.

[Frangible]

I would venture that Cameroon, and Kenya too, wants Canada to lead the investigation because the Canadians conducted the Abidjan enquiry, and nothing came out for years.
That's probably what they are counting on. After all, the priority here as far as Cameroon CAA, Kenya CAA, KQ and the respective governments is the same. If any egregious mistakes were made they must remain secret, at least for as long as possible. The causes of the Abdijan crash were well obscured, greatly delayed and no official report was ever published. That's what they will be hoping for this time.
Can the NTSB be relied upon to keep schtumm? I think the Africans think not. They have this terrible habit of getting "lessons learned" out to all and sundry. Cameroon and Kenya will unite to prevent this.

Neutrality, my shiny metal butt!!

[threemiles]

of the Abdijan crash were well obscured, greatly delayed and no official report was ever published

???

http://www.bea-fr.org/docspa/2000/5y-n000130a/pdf/5y-n000130a.pdf 25.7 Mb PDF file

Though it is from a french speaking agency it is not originated in Canada

[Frangible]

my bad. Sorry, but the point about delay still stands.

Crash: Jan 2000. Report: Feb 2004.

[Beanbag]

It seems the authorities are pointing fingers now - following is from Airwise News:

Quote:
--------------------
The pilot of a Kenya Airways plane that crashed in Cameroon this month decided to take off in stormy weather while other flights waited for conditions to improve, Cameroon's civil aviation chief said on Tuesday.

Cameroon has launched an investigation into the crash of the six-month-old Boeing 737-800, which crashed into swampy jungle not far from Douala Airport shortly after taking off around midnight on May 4-5. All 114 people on board were killed.

Relatives of the victims have criticized Cameroonian authorities over their handling of the accident. Search parties took nearly two days to locate the plane wreckage, which was found less than 6 km from the end of the runway.

The head of Cameroon's Civil Aviation Authority, Ignatius Sama Juma, said the Douala control tower had advised the captain of Kenya Airways Flight 507 of the stormy weather conditions.

"Certainly, there was a storm problem," Sama Juma told Radio France Internationale, adding that only the official inquiry would determine whether the crash was caused by a technical fault or human error.

Sama Juma said the captains of two other planes also due to leave Douala the same night both decided to wait for weather conditions to improve. They left safely.

"The control tower gave all the meteorological information to the commander of (the Kenya Airways) flight... but he decided to take off... it was his decision," Sama Juma said.

There were angry scenes near the site of the crash on Monday when Cameroonian soldiers prevented a group of relatives of crash victims from visiting the location because they said the accident site required further work.

The dead passengers came from 27 nations, mostly African, but with others from China, India, Europe and elsewhere.

Only one "black box", the flight data recorder, has been recovered. Rescuers were looking for the cockpit voice recorder.

Responding to criticism that Cameroonian authorities wasted nearly two days searching for the plane 150 km from the crash site, Sama Juma said the automatic distress beacon on board had stopped transmitting soon after take-off.

"When the crash took place... we think the beacon was immediately destroyed... it stopped transmitting, so that made precise location more difficult," the official said.

He added the search was misled by data provided by a satellite tracking station in Toulouse.

Sama Juma said Douala Airport did not have a ground surveillance radar, which would have made it much easier to locate the wreckage. "It's expensive to install surveillance radar," he said.
------------------------
End of quote

[bear11]

God help us if it's true - shades of the B732 ADC crash last October in Nigeria. Friends who have flown in Africa have described the sometimes shameful pressure they have been put under to operate flights "on time" (ie; African "on time") in conditions that were not fit to fly in. Or are they just trying to fit up a dead pilot as usual?

[SeniorDispatcher]

A couple of bits and a photo in this latest edition:
http://www.flightglobal.com/articles/2007/05/15/213845/investigators-trawl-swamps-for-clues-on-kenya-737-crash.html

[vapilot2004]

Slow progress in investigation.

Slow crash inquiry frustrates U.S.

The investigation into the May 5 crash in Cameroon of a new Boeing 737-800 has been so slow and frustrating that some members of a U.S. team sent there to help have returned home.

A U.S. government source, speaking on condition of anonymity, said members of the U.S. team only recently were able to begin a detailed examination of crash wreckage.

Even more frustrating for investigators, the source said, is the delay in analyzing the Kenya Airways plane's flight data recorder. One of two so-called black boxes on the plane, it was found shortly after the crash site was located, but local authorities have refused to send it away for examination. Cameroonian authorities apparently have not been able to decide who should have jurisdiction.

The flight data recorder could provide valuable clues to what caused the plane to crash shortly after takeoff, apparently during a storm. All 105 passengers and nine crew members were killed.

Nearly 1,200 of the Boeing 737-800 models are in operation around the world.
Of two Boeing Co. investigators sent to the scene after the crash, one has returned to Seattle. The lone Federal Aviation Administration representative also has left. And some members of a National Transportation Safety Board team have pulled out, the source said, although the lead NTSB investigator is still there.

Boeing, the FAA and the safety board all declined comment Thursday, although a Boeing spokeswoman confirmed that the company still has one person at the scene.

Aviation experts say the slow pace of the investigation is typical of what can happen after a jet crash in Africa.

But it is important that the flight data recorder be examined as soon as possible, said John Nance, a former 737 pilot for Alaska Airlines and an aviation safety consultant.

This was a new Boeing jet, he said, and there so far are few clues as to what may have happened. The crash could have been weather-related, the result of pilot error, a mechanical problem or even sabotage, he said.

It's important that U.S. experts not be hindered in their investigation, he said.
Media reports from Kenya and Cameroon have said the two countries have been unable to agree on who should examine the flight data recorder.

A Kenyan official has been quoted as saying that country would like the flight data recorder to be examined by Canadian authorities rather than the NTSB to avoid bias. But the decision is up to officials in Cameroon, who reportedly want the French to analyze the data.

Boeing said the flight data recorder on the jet is one of the latest models and was able to record 1,000 parameters of information. For investigators, that could provide a gold mine of clues about what went wrong.

The jet's other black box, which would have recorded the conversations in the cockpit between the two pilots, as well as the sound of any alarms going off, has not been found.

In addition to the squabble between governments over the flight data recorder, the investigation has been hampered by the location of the crash -- in a swamp. Most of the wreckage remains buried in muck.

Kenya Airways Flight 507 went down near the village of Mbanga Pongo near Douala, Cameroon. The Boeing 737-800 was headed for Nairobi.

It was a new plane, delivered by Boeing in October to Singapore Aircraft Leasing Enterprise, which leased it to Kenya Airways. The airline took delivery of two other 737-800s from the leasing company last year.

The jet that crashed had accumulated fewer than 500 cycles, according to Boeing. Each takeoff and landing counts as a cycle.

It was only the second crash ever of one of Boeing's next-generation 737s in which passengers were killed. The first occurred in the heart of the Amazon jungle over Brazil in September when a 737-800 operated by Gol collided at 37,000 feet with a private jet. The private jet did not have cockpit equipment turned on that could have alerted the pilots that they were on a collision course with the airliner.

All 155 people onboard the Gol 737 were killed.

Until the Gol accident, the only fatal accident involving a next-generation 737 occurred when a Southwest 737-700 was unable to stop after landing in a snowstorm at Chicago's Midway Airport. The plane went through a fence at the end of the runway and hit at least two cars, killing a 6-year-old boy in one.

Boeing makes four next-generation 737 models -- the 737-600, -700, -800 and -900. The first to enter airline service was the 737-700, with Southwest in December 1997.

More than 2,000 next-generation 737s are in operation with airlines around the world.

The 737-800 entered airline service in spring 1998. It has become the best-selling of the next-generation models.

Through April, airlines had ordered 2,174 of the 737-800s, according to Boeing. About 1,000 of those have not yet been delivered.

[Pinkman]

None of us who have lived and worked in the region are surprised at this - there are those that would breathe a sigh of relief if, like so much else on the dark continent, it went 'missing' - irrespective of what it might reveal. The immediate victims of this procrastination are the relatives of the deceased who seek answers to in a small way explain their loss. Longer term, every day that goes by increases the chance that the data will be lost or compromised and lessons that could benefit aviation in general and African aviation in particular, will be lost.
Who are the stakeholders?
- Colonially, Cameroun is culturally tied to France, as Kenya is to the United Kingdom.
- The passengers/relatives: amazingly, there were no Kenyans on the flight, save the crew
- Kenya Airways has some links to the United States, the Netherlands and France through the KLM/Northwest and KLM/Airfrance / Skyteam linkages
- Boeing is of course tied to the United States
- The aircraft lessor may have some influence
Its probably not the sort of issue that would be discussed at the UN, but in sorting through this sordid and unacceptable squabbling, the African Union has a chance to show some statesmanship and resolve the issue in a heartbeat. John Kufuor (the president of Ghana) is the current head of the AU, which is based in Addis. Neither of these countries have a stake. All that is required is that Kenya and Cameroun agree to resolve the dispute at the AU. That is what its for. South Africa might have been an intermediary if it had the equipment, which I don't believe it does (?) but realistically I think there is now only one place for the CVR and the FDR to go: Canada. Canada is close and culturally similar enough to Seattle to satisfy Boeing. It is surely Francophone enough to mollify Cameroun, who hold the cards as the state of occurrence. And its hopefully anglophile enough to satisfy KQs desire for independance. Surely?

[lomapaseo]

The examination of the DFDR should proceed straight away.

The Cameroons as state of occurrence have first rights to direct who should decode it and of course under Annex 13 all parties have a right to participate.

All this crap about vested interests and dithering of data is just news fodder for public sale of newspapers.

[barit1]

Interesting window into the the interface between flyers and journos:

http://www.salon.com/tech/col/smith/2007/05/18/askthepilot232/

Read and heed! :eek:

[ChristiaanJ]

Thanks, barit1.

The examination of the DFDR should proceed straight away.Talk about kicking in an open door......
Don't hold your breath, it won't happen soon.

[Pinkman]

Quote: "All this crap about vested interests and dithering of data is just news fodder for public sale of newspapers"

Well Lomopaseo, just shows how little you know about Africans and the complex relationships on the continent.

You will know that Annex 13 states that: "The State of Occurrence shall institute an investigation into the circumstances of the accident and be responsible for the conduct of the investigation, but it may delegate the whole or any part of the conducting of such investigation to another State by mutual arrangement and consent"

It is perfectly clear that Cameroun does not have the facilities to analyse the DFDR and that it will need to contract a substantial portion of the investigation to another state. To do this without consulting the other stakeholders would be foolhardy, as this is a highly sensitive political issue. If you do not recognize that then clearly you do not understand African politics and I suggest you refrain from comment.

[prospector]

Whilst it is possible to agree with your conclusions as to the state of facilities, the reason you give for arriving at them is a gross oversimplification and a disservice to the many who spent their lives trying to engender change. Classic examples of self determination, without colonial help, is quite apparent in other countries on that continent.

[ericferret]

It isn't just Africa, look what happened to the Kursk.

At least the Russians learnt and the next time a sub got into trouble they get the best help available.

First law of international relations.

"National pride increases in direct proportion to national incompetance"

[fractional]

"National pride increases in direct proportion to national incompetance"
Right said Ericferret. This is also applicable elsewhere in our lives.:ouch:

[lomapaseo]

Politics and beliefs aside.

The only thing that matters in this thread is whether the signatories of ICAO Annex 13 among them will abide by what they signed for. Each signatory government had their opportunity, before signing, to exclude any provision that was not in keeping with their country's rules or regulations.

Now they are bound by what they signed for under ICAO.

[wes_wall]

"The only thing that matters in this thread is whether the signatories of ICAO Annex 13 among them will abide by what they signed for. Each signatory government had their opportunity, before signing, to exclude any provision that was not in keeping with their country's rules or regulations."



I fear that a mere liquid signature on a piece of paper will have little bearing on what ultimately happens with the investigation. Recall, these countries are often referred to as “Third World,” and this is with rightful qualification. Those truly responsible for moving the event forward are more likely to be more protective of their position, security, and personal greed. Odds are the FDR may never see the light of day, and if so, in what readable condition. I only hope that if there is something wrong with the airplane that another accident is not necessary for us to find out. I shake my head at the doubt and suspicion which is placed before common sense and the safety of others.

[lomapaseo]

I fear that a mere liquid signature on a piece of paper will have little bearing on what ultimately happens with the investigation. Recall, these countries are often referred to as “Third World,” and this is with rightful qualification.

I don't like the abstract use of the term "Third World" in the context of this subject. "Third World" to me implies that "they" don't have rules and regulations according to the standards of the rest of ther world or that they fail to enforce such standards. here we are talking about the standards under Annex 13 that are in place (qualified under their signature) and need be enforced by ICAO with some sort of consequences if they are not upheld.

So casting this off as predictable third world behavior is too quick a judgement in my mind.

Else why does aviation even bother with ICAO standards unless we intend to abide by them.

[Dogma]

Lomapaso

How about the Terd World?

In my view West Africa, typifies the worst excesses of the Third world. Cameroon is a little more progressive but the handling of this disaster makes it appear more like its neighbour Equatorial Guinea.
More pressure must be applied to the authorities involved, the families need accurate answers! :ugh::mad:

[Pinkman]

Dogma, I agree.

So you would imagine therefore that the various associations (IATA, IFALPA and particularly ICAO) would have made statements to that effect or in the case of ICAO an offer to help resolve the impasse, wouldnt you? I'm sure its all going on behind the scenes but some transparency would help.

PM

[Dogma]

Sorry but back to the Top of the Forum.

Can any one shed some much needed light and latest info on this horrific tragedy ???:ugh::mad:

[threemiles]

FDR not submitted yet? Unbelievable.

Who would be liable if it would contain evidence of a mechnical failure (let's say a reverser stowing valve f.i.) and that same failure would lead to another accident before the FDR is sent in?

Cameroon? Kenya? ICAO?

[wes_wall]

Not hard to understand why - Consider the mentality of why and who has control over the next step. Standards be damned. Mark my words, it will be a long long time before any useful information surfaces - no pun . Too bad.

[ChristiaanJ]

FDR not submitted yet? Unbelievable.
Who would be liable if it would contain evidence of a mechnical failure (let's say a reverser stowing valve f.i.) and that same failure would lead to another accident before the FDR is sent in?
Cameroon? Kenya? ICAO?Possibly all of the above....
So if another accident happened, who would you sue, and how would you pay the lawyers?
You and I still live in a world where we think that getting an answer to what happened, and preventing a recurrence, is the first priority.
We are the dinosaurs.
The priority now is procrastination, obfuscation, and generally covering your a$$.
What really happened has become irrelevant.

[AfricanSkies]

Where can one find historical METARs and TAFs ? I noticed someone posted METARs by the hour on the day of this accident. Anyone got a link please?

[global718]

Just returned from Cameroon. FDR was submitted more than a week ago. Has been analysed. CVR has not been recovered yet. crater is 40-50FT deep and floods daily with tide coming in and out. Its very difficult to work as sight is difficult to get to. Talk of digging up sight now. Boeing and NTSB on sight assisting. Kenya Airways is doing its utmost to get to the bottom of this tragedy.

[wes_wall]

Encouraging. Do you know where or to whom (Country) the FDR sent.

[global718]

FDR was sent to Canada.

[punkalouver]

My source at Kenya Airways, without commenting directly on this particular accident, says that the Flash Airlines report was a very, very interesting report.

[gwillie]

...the Flash Airlines report...
Anyone have a link to this?

[hetfield]

http://www.b737.org.uk/flashair.htm

[threemiles]

Spatial disorientation during a 270° turn over water, overbank

[punkalouver]

And thinking the autopilot was engaged. Remember that when engaging the autopilot to make sure the autopilot is engaged, not just the flight director. Proper unusual attitude recovery techniques are important as well.

[Belgique]

In mid-air, plane’s key panel goes blank
SANJAY MANDAL
.
"This is an emergency. I am not getting the proper data. None of the navigational panels are working properly..."
The Mayday call to the Calcutta air traffic control (ATC) was from the Hyderabad-bound SpiceJet flight SG 527 minutes after take-off on June 6. There were 132 passengers on board.
In what was termed by airport officials and pilots as an “extremely rare and dangerous situation”, the aircraft’s essential gadgets measuring height and speed and fixing direction were malfunctioning. A disaster was averted by the pilot’s SOS to the airport and then the surveillance radar that navigated the craft back to safety.
.
The Boeing 737-800 series left Netaji Subhas Chandra Bose International Airport at 2.47pm. Once airborne, the control of an aircraft is handed over to the surveillance radar from the ATC tower but the officer in the control tower keeps in touch with the pilot.
.
“The pilot was not responding to our calls. We were very worried,” recounted an official of the directorate-general of civil aviation (DGCA)’s air safety wing.
Then, the pilot’s voice reached ATC officers. “He sounded really nervous,” the official added.
And with good reason. The pilot told the control tower that the altimeter (measuring the height at which the craft is flying), the heading (compass on the panel showing the direction in which the craft is flying) and the speed control system were not displaying the vital information.
“The craft was then flying at an approximate height of 3,000 feet above ground level and steadily gaining height. But the pilot had no clue which way he was heading, the height at which he was flying and its speed,” an official explained.
.
The pilot told the control tower that he needed to return to Calcutta airport at once. “A full emergency was declared at the airport; we had never faced such a situation,” an ATC official admitted.
SG 527 was then completely guided back to the runway by the surveillance radar. The pilot was first told to turn in a particular direction, then asked to lower height and decrease speed as directed by the radar. The aircraft landed just after 3pm, amidst all emergency arrangements.
“It was an operational issue which was resolved. The flight landed safely and nothing major happened,” said a SpiceJet official.
But veteran pilots shuddered at the thought of what might have been. “It is a very rare situation and can be really dangerous,” said one. “After take-off, if the speed limit is crossed, the aircraft’s whole structure can be damaged. And the wrong reading of heights can increase the possibility of mid-air collision,” he pointed out.
.
from this link (http://www.telegraphindia.com/1070612/asp/calcutta/story_7910011.asp)
.
Any prior recorded instances of this on 737NG?
Any AD's or Service Bulletins, SIL's issued?

[atakacs]

Good airmanship, even if over exaggerated (I'm pretty sure there was some minimal backup equipment working).

Anyone with more info ?

[Another Number]

“The craft was then flying at an approximate height of 3,000 feet above ground level and steadily gaining height. But the pilot had no clue which way he was heading, the height at which he was flying and its speed,” an official explained.Gives new meaning to IFR: No need for situational awareness! :}

[PPRuNe Towers]

Belgique,

The was an apparently similar event in the US last year. The no publicity box appear to have been ticked but we do get wind of such things here at the Towers.

If I remember correctly hud and standby data remained along with the good ole whiskey compass. No news here as to when to expect a public report but that doesn't mean there isn't already information in the public domain.

Regards
Rob

[forget]

Good airmanship, even if over exaggerated (I'm pretty sure there was some minimal backup equipment working).

http://i21.photobucket.com/albums/b270/cumpas/1221264.jpg

[Belgique]

From my reading of this AD (http://content.atp.com/ADs/pdf/070652.pdf?JServSessionIdroot=vvfl8n97n1.JS2), it claims to replace the original emergency AD that cited spoiler actuator problems on 737-800SFP models (i.e. short-field performance variants).... and increases the scope of its model coverage (i.e. beyond the SFP). It was, from the wording of the original emergency AD, then generally assumed that non-SFP aircraft were unaffected by the spoiler glitch. However at the link above we read:
.
"SUMMARY: This document publishes in the Federal Register an amendment adopting airworthiness directive (AD) 2007-06-52 that was sent previously to all known U.S. owners and operators of Boeing Model 737-800 series airplanes by individual notices. This AD requires inspecting spoilers to determine spoiler position after every landing and after any rejected takeoffs. For airplanes on which any spoiler is found in the up position with the speedbrake handle in the down position, this AD requires replacement of the flight spoiler actuator with a flight spoiler actuator having a certain part number." etc etc
.
It still says: This AD results from a report of seven flight spoiler actuator jams on Model 737-800 Short Field Performance airplanes. but later explains:
.
"Since the unsafe condition described is likely to exist or develop on other airplanes of the same type design, we issued emergency AD 2007-06-52 to detect and correct any spoiler panel that is found in the up position with the speedbrake handle in the down position, which could result in a spoiler actuator hardover, and could cause the spoiler surface to jam in the fully extended position. Two or more hardover failures of the spoiler surfaces in the up direction on the same wing, if undetected prior to takeoff, can cause significant roll and consequent loss of control of the airplane."
.
and (perhaps of paramount concern):
.
"The takeoff configuration warning will not sound if any flight spoiler remains extended with the speedbrake handle in the DOWN position. The cause of the failure has been identified as interference within the actuator main control valve."
.
This would seem (to me) to infer (via its timing and verbiage) that the problem extends beyond the SFP model and that the spoiler glitch may indeed have been a possible factor in the Douala accident.
.
Agree/disagree?

[arcniz]

Very provocative, Belgique, but the connection or likelihood of these items seem speculative and tenuous, at best. Do you have more specific information that would tie these possible failure modes to Douala?

If I am following your post, You have cited two seemingly unrelated circumstances ( flight instrumentation faults on departure, spoilers non-retracted after landing ) as if they were connected and possibly causal in regard to Douala. Do you see a tangible link?

Certainly would be the definition of a BAD day to have those two problems while departing, at night, into an intense thunderstorm.

[Dogma]

Belgique

I have raised this earlier, only to be told that this aircraft was not affected by the AD.

Have they found the CVR - It cannot be beyond retreval, mine the f:mad:er out if necessary!

[bushbolox]

Stop over complicating it. Poor weather, new dispalys, reversion under stress to old scans. My money is on disorientation during or after an upset, failure to recover due to lack of time. The same would probably kill any of us.

Time will tell if Im right.

[UNCTUOUS]

Belgique
I have raised this earlier, only to be told that this aircraft was not affected by the AD.
.
Think the point Belgique is making is that the Emergency AD (-51) was reissued as -52 to cover the fact (as soon as Boeing realized it) that more than the SPF model of the 737-800 was involved.
So if the aircraft did takeoff with a spoiler or two UP (because the takeoff configuration warning would not be activated in this scenario), then it's conceivable that around about 30 secs after takeoff (the actual scenario) roll control would have been lost (or at least a huge factor as the airplane accelerated to climb speed).
.
Can't see the error in that logic.

[20driver]

If the condition covered by the AD-52 mentioned above did occur i.e. handle down, spoiler up what would the FDR show? Does it record spoiler position, handle position or both?
Just curious, not making any assumptions.
20driver

[CaptainSandL]

From the AP 16/6/07

A search team has found the cockpit voice recorder of a Kenya Airways plane that crashed in Cameroon last month, killing 114 people, the airline's chief executive officer says.

The voice recorder was found on Friday afternoon and Cameroonian authorities are now making arrangements to get it to Canada as soon as possible, Kenya Airways CEO Titus Naikuni said in a brief statement.

When it is analysed, the voice recorder is expected to reveal the final exchanges between the plane's captain and his co-pilot and also any conversations with the control tower in Cameroon's commercial capital of Douala.

The Kenya Airways flight nose-dived into a swamp in the West African country less than two minutes after taking off from Douala on a stormy night on May 5. The Boeing 737-800 had been bound for Kenya.

The plane's data recorder was found last month and taken to Canada for analysis. A preliminary review showed no evidence of a mechanical malfunction, the Cameroon Civil Aviation Authority said in a statement posted on its web site.

The authority said a full report of what led to the crash will take as long as a year.

The preliminary investigation found that all crew members were sufficiently trained and certified according to expected aviation guidelines, the statement said

[I Just Drive]

People are adding 2 and 2 and getting 5. Lets wait for a formal investigation and subsequent outcome. The 800 has a couple of weak areas but overall it is an astonishing aeroplane. I, (as someone who drives one nearly daily), await with eager anticipation the outcome. I don't think it is helpful to try and make various ad's and previous incidents fit this one. At this stage who the hell knows? Maybe a bee flew in and stung them both to death.

I'm ready to be shot down, go ahead.

[Feline]

I'm kind of puzzled that the CVR was found "a few kilometers from the crash site". I thought that the black boxes were a pretty integral part of the plane, so how did the CVR detach itself so far from the actual crash site? Unless some local picked it up as a trophy? Very strange ...

South African Sunday Times 17 June 2007:

The cockpit voice recorder (CVR) was located a week ago in the marshy area around the village of Mbanga-Pongo, a few kilometres from Douala, where the Boeing 737 came down on the night of May 4.

[Brat]

There will, as always, be a ton of crud to trawl through for the nuggets of informed and expert relevence that are contributed in threads like these. Having followed a few it has always been apparent is that yes, there is a lot of speculation, however there is also much that can be learned from informed contributions. Particularly as the facts sadly do take months, sometimes years to come out.

The fact that people died is a tragedy. Kenya runs a very professional operation but the sad fact is that even in the best no matter who, crew mistakes can and do happen, and malfunctions can and do happen even to the newest and best maintained equipment.

It is frustrating that in Africa things happen a bit slower but vital boxes have been found and hopefully at some stage information will be processed and the causes pinned down.

[ChristiaanJ]

Feline,
If your post was based on the item you quoted from the South African Sunday Times, I think you just misread the phrase.
I read it as:
"The cockpit voice recorder (CVR) was located a week ago in the marshy area around the village of Mbanga-Pongo, where the Boeing 737 came down on the night of May 4. The crash site is a few kilometres from Douala, from where the aircraft took off."

[Feline]

CJ - Yes - I think you are right. Thank you!

[kingair9]

Quote: "All this crap about vested interests and dithering of data is just news fodder for public sale of newspapers"

Well Lomopaseo, just shows how little you know about Africans and the complex relationships on the continent.

You are the lucky one here - I wrote about the same approx. 10 pages before. I have worked in "black Africa" for years (not as pilot) and I was bashed by some senior members of this forum for speaking things like this loud...

[sawaya]

The Cockpit Voice Recorder of the Kenya Airways flight that crashed in Douala, Cameroon, has been recovered.
Kenya Airways chief executive officer, Mr Titus Naikuni, said the gadget was recovered on Friday by the search team that has been at the site since accident occurred one month ago.
"The Cameroonian authorities are making arrangements to get the CVR transferred to Canada," he said, in a statement.
The KQ management has already announced plans to compensate the victims.
Investigation into the incident is still ongoing.
The six-month old Boeing 737-800 crashed close to Douala airport shortly after taking off for Nairobi in stormy weather at around midnight on May 4-5 killing 114 people on board. Much of the aircraft broke into fragments little bigger than a car door.
Rescuers had already retrieved a first "black box", the in-flight data recorder, but the voice recorder should contain the last minutes of conversation between the pilot and co-pilot and is expected to help determine the cause of the crash.
Efforts to retrieve it had been hampered by heavy rains, which constantly refilled craters emptied by rescue workers, turning the site into a quagmire.
It took nearly two days to locate the plane’s wreckage after fruitless searches in the tropical forest, which Cameroonian officials have blamed on misleading information from a French satellite station.
The central African country’s civil aviation chief said the pilot took off in stormy weather.

[threemiles]

bump

no news?

The CVR is in Canada since 2 weeks, the FDR since 6 weeks?

[wes_wall]

I would not anticipate any information out of Canada until their findings are completed, or unless there is something CONFIRMED FLAWED with the airplane. They normally do not release any CVR info prior to final reports.
It will be a while before any info is forthcoming.

[bobusse]

Should anything to be corrected on the aircraft,we would hear from the manufacturer(AD or else),for all other reason we'll have to wait.

[B777Heavy]

I read a couple of days ago again in one of the local Kenyan Dailies that the airline & pilots have been exhonarated as far as currency,cerification, maintenance and etc .....

Let me see if i can find a link and I will post it

[Frangible]

Canadians never release anything from CVRs, not even selective transcripts, because of their famed privacy laws. The Kenyans or Cameroonians would be able to if they wanted to.

[B777Heavy]

Sorry guys.....cant find the link

[ChristiaanJ]

B777Heavy,I read a couple of days ago again in one of the local Kenyan Dailies that the airline & pilots have been exonarated as far as currency,certification, maintenance and etc .....Another local "official" making "statements" well before there are any significant results from the inquiry.
Can't really blame him.... he's trying to reassure the punters.

[atakacs]

Canadians never release anything from CVRs, not even selective transcripts, because of their famed privacy laws. The Kenyans or Cameroonians would be able to if they wanted to.

SR111 transcripts were available well before the end of the investigation...

[Frangible]

Those were ATC transcripts. Nothing from the CVR at all. Just a small amount of reported speech.

[wes_wall]

The only info on the SR111 CVR recordings was the very early leak (October '98) by ABC News. A reporter obtained a CVR transcript from who knows who and the network revealed the detailed contents. Obviously, it generated quite a stir with the Canadians, and the Network did not dwell on the topic again.

[wes_wall]

Bump - has there been any addition information been released? Thanks.

[threemiles]

another bump
very strange - a huge fleet of B737-800s out there and no news, no prevention, no lessons learnt (yet)?

[Swiss Cheese]

Boeing did make a non-announcement about 7 weeks ago to operators (as did the Cameroonians to the world in their prelim report) that the DFDR revealed no "mechanical defect". Deafening silence on any other defect - whether electrical, hydraulic or indeed otherwise. As to the spoiler AD issue, the consensus seems to be that the DFDR would not have revealed a configuration anomaly. Perhaps their lawyers are using weasel words.....?:hmm:

[bushbolox]

Rainboe,
Dont hold your breath. With the track record of the authorities involved and the aircraft vendors global interests at stake I doubt you will find anything out....that is true.
Just like the abijan airbus. pages of technical theory and not one mention of the training record of either pilot vis a vis poor ability, nepotism or similar disaster avoided previously .
Been there seen the film , ate the pie met the rabbits

[threemiles]

http://en.afrik.com/article12400.html

[frogone]

It's dated Tuesday 11 December 2007

IR

[glad rag]

Indeed Rainboe, it gratifying that the investigation has been carried out in such a thorough and transparent manner.

[bushbolox]

The many KQ crew i have chatted to down route are already aware of the cause. Goback to the early days of this thread and it has already been touched upon. As rainboe says it will hit between the eyes.
Accidents are based on probability. Much is done to mitigate the odds.
Past reputaions are based on past miitgation. Present reputations are based on current mitgation. Hence this thread.

[punkalouver]

According to my source at Kenya Airways, a perfectly good plane clear of weather on a dark night flown like the Flash Airlines 737 in Egypt.

[Diamond Bob]

Report on Kenya Airlines Crash to be Finalized. Or so says this article --


Business Daily: - Company Industry|Report on Kenya Airways plane crash finalised (http://www.businessdailyafrica.com/Company%20Industry/Report%20on%20Kenya%20Airways%20plane%20crash%20finalised/-/539550/904690/-/a8aghbz/-/)

[atakacs]

Is it public ?!

[Airbubba]

April 27, 2010

Pilot Error Blamed for 2007 Crash That Killed 114

By THE ASSOCIATED PRESS
Filed at 9:51 p.m. ET

NAIROBI, Kenya (AP) -- A newly released investigative report into the 2007 crash of a Kenya Airways flight in Cameroon that killed all 114 people on board blames pilot error.

The report -- which took almost three years to be released -- says the Boeing 737-800 slowly banked right after a midnight departure on May 5, 2007, and that when the pilot finally noticed he aggravated the problem by banking even farther to the right. The report says the captain had a case of ''spatial disorientation.''

The airplane went into a spiral dive and crashed less than two minutes after takeoff. The plane had been delayed by a thunderstorm but the report says the weather was not likely a cause of the accident.

All 108 passengers and six crew died.

http://www.nytimes.com/aponline/2010/04/27/world/AP-AF-Kenya-Cameroon-Crash.html

[kotakota]

Did he 'think' he had engaged autopilot , but did not check CMD annunciation because of preoccupation with weather radar ?

[EatMyShorts!]

That reminds me of my colleagues who died in the crash of the Saab340B of Crossair in Zürich. Did the Captain, in this case, chew too much Khat before the flight? Sad story.

[HeadingSouth]

The Crossair Saab went - to the best of my information - down because they had a Moldavian Crew Member who was PF - and the eastern Pilots were used to a different Artifical Horizon design (apparently western horizons have the plane fixed and ground moving, whereas eastern horizons have ground fixed and plane moving).

I don't know about eastern planes and training on them in Africa but would guess this was not a factor in the Cameroon crash.

[PLovett]

EatMyShorts!,
A rather sad commentary on racial stereotyping don't you think?

Loosing spatial awareness seems to be the new way of committing industrial homicide with Flash Airlines, Ethiopian Airlines (suggested at this stage) and now Kenyan Airlines. I am sure there have been others.

Are we getting to the stage that pilots can no longer hand-fly on instruments? Do they have to have their hand held by the autopilot? Is airline training so concentrated on learning the automation that we have forgotten there is an aircraft to be flown.

This is basic stuff that should be bread-and-butter to an airline pilot. Isn't it time the slide in skills was addressed before more of this happens?

[PEI_3721]

Disorientation comes in many forms and in many circumstances.
No one is immune; vulnerability varies with task proficiency and the commitment to manage personal attention when scanning instruments and systems. In addition, there can be human aspects including fatigue and previous experience; then there are (should be) defenses from team/crew aspects – cross monitoring and alerting.

Autoflight systems are ‘dumb but dutiful’; normally they will provide warning of failure or extreme manoeuvre, but a significant ‘communication’ weakness is that these depend on the system being engaged.
Handing control to another pilot can be confirmed with a “You have / I have control” routine, but autoflight systems don’t talk when engaged, sometimes they shout (warn), and they can bite. Thus correct engagement and initial operation must be checked visually and then announced stating active modes and anticipated changes (e.g. Autopilot engaged, Speed and Hdg; VOR and Alt armed).

It’s interesting to note different ‘safety cultures’ indicated by the media headlines – “Pilot error, Blame …” (NY Times) I wonder if the NTSB’s assistance used those terms, and the positive and professional view in “Poor airmanship” (Flight Global).
The latter offers hope of working on specific issues which can be improved - practice, attention management, knowledge, situation awareness (autoflight monitoring), and judgment (particularly of how and when to hand over control).

For other info see the visual guide ‘Understanding Spatial Disorientation’ at Aviation org – free registration for access to all of the library.

[gtf]

It's a pretty large file due to the graphics included. Make sure you have lots of time and coffee.
http://www.ccaa.aero/images/blogs/d033e22ae348aeb5660fc2140aec35850c4da99744f683a84163b3523afe 57c2e008bc8c/rapport%20kenya.pdf

[keitaidenwa]

I'm not sure if that site is in cameroon or why it was slow to download. I suggest to be polite to the site and download the 40MB pdf only if intending to read it too.

The line proficiency checks of the captain highlited "performance deficiences". From the report:

- November 2002, route training assessment was converted to a training flight because the captain demonstrated inadequate knowledge of procedures and airline systems, including FMA, AFDS and fuel management.
- In July 2004 the captain went through route profiency training and check because of his decision to initiate diversion on scheduled passenger flight due to an standby ADI failure. this was seen as a indication of "lack of understanding airplane systems and redundancies that are built into the system."
- In August 2006 annual line check was judged to be below standard for a captain, leading to another check in november 2006

In the conclusions section:

32. The results of flight checks for technical flight personell were reported without any complacency, but not sufficiently exploited by operator.

[Huck]

including FMA

Bingo.

Live another day, check your FMA.....

[dvv]

A copy of the report with OCR'd text embedded is available here:
http://busybee.dvv.org:8000/flying/rapport%20kenya.pdf

[noelbaba]

tourismandaviation.com
Ünal Başusta

The Boeing 737-800 airliner plunged into a mangrove swamp on a stormy night minutes after taking off from Douala, the west African nation's largest city, en route to Nairobi.

Pilot error and spatial disorientation during a thunderstorm was the probable cause for the crash of a Kenya Airways jet in Cameroon on May 5 2007, which killed all 114 people on board.

The crash report, compiled by the Cameroonian Civil Aviation Authority, found the captain didn't adhere to standard operating procedures and the plane took off without authorization from air traffic control.

Investigators have concluded that crew's poor airmanship was the reason for their not recognising and correcting an excessive bank angle during climb after take-off, leading to the crash.

After lifting off runway crew did not properly scan their instruments despite the lack of external visual references on a dark night. Due to their poor situational awareness they had spatial disorientation and failed to recognise the aircrafts slow banking to the right, which was initially corrected by the captain who was the flying pilot.

Some 42 seconds after the 737 became airborne the captain called 'OK, command'. While this signalled the activation of the autopilot, the autopilot did not engage and there was no confirmation of the autopilot's activation from the first officer, cockpit annunciator, or the behaviour of the aircraft. But the crew believed and acted as if "the autopilot was effectively engaged".

While they were dialing the right numbers for the heading select panel and altimeter, they both failed to recognise, from the instruments, the aircraft's increasing bank to the right. When they called for autopilot engagement the bank angle was already about 11°. Because they failed to engage the autopilot the bank angle continued to increase to 34° and a 'bank angle' warning sounded in the cockpit.

Untill that time they appeared to be "unaware" of the excessive bank angle and the auto pilot was not engaged. The captain expressed surprise at the alarm, and worsened the situation by first turning the control yoke to the right and thus increasing the bank angle more.

Then the captain became disorientated more, instead of trying to level off the plane manually he activated the autopilot first but at the same time handled the flight controls thus making autopilot unusable.

The right bank increased to 80°, after reaching a height of about 2,900ft, the aircraft pitched nose-down, banking eventually to 115°.

Flight-data recorder information indicates that, at one point, the two pilots were providing conflicting inputs to the aircraft's control column: the first officer was turning the control yoke left, with nose-down, while the captain was turning it right, with nose-up. That indicates none of crew recognised the true situation of the aircraft and were unable to give the right commands to make it recover at any time.

About 90 seconds into the flight, under those conflicting commands the aircraft banked beyond 90 degrees, descending into a downward roll, and the captain was heard saying ''we are crashing.'' Seconds later the 23 years old first officer mistakenly told the pilot to turn right, before correcting himself and saying "Left, left, left captain". The plane crashed nine seconds later, a minute and 42 seconds into the flight.

The report was posted early Wednesday on the website of the Cameroon Civil Aviation Authority (CCAA). Some of the investigation was conducted by the U.S. National Transportation Safety Board as well as Boeing experts in the United States and specialists in Washington and Pensacola regarding the effects of spatial disorientation.
"Spatial disorientation is a condition in which an aircraft pilot's perception of direction does not agree with reality".

Mr Maigari was the head of the Technical Commission that carried out investigations into the accident. The two black boxes -- one that records the flight data, and the cockpit voice recorder which records conversations between the captain, copilot and air trafic controllers -- were found on May 7 and June 9 respectively.

The CCAA cites a "lack of rigour" in piloting and It adds that the pilots' "inadequate operational control" and failure to co-ordinate contributed to the accident.

The report noted that the captain was 52 but that the first officer was only 23. Before takeoff the pilot admonished his first officer for turning on the plane's windshield wipers, and the report speculated that the first officer, already a shy person, did not speak up to tell the pilot about the aircraft banking when he should have because of their relationship.

The report said that the plane's manufacturer, Boeing, doesn't sufficiently explain rudder trim modifications due to temperature variations during climb and descent. But it added that the amount the plane was pulling to the right should have been easily correctable by the pilot.

Kenya Airways, which is 26 percent owned by Air France-KLM, said it had reservations over the report's findings that the pilot had not properly engaged the autopilot after take off. "One (reservation) is to do with the auto pilot, CRM (Crew Resources Management) and safety programme implementation," Titus Naikuni, the head of Kenya Airways, told reporters.

The report also said the Boeing flight manual did not include full information on the ability of the aircraft's autopilot to roll the airplane to a safe degree of banking from a dangerous level.

An aviation analyst in Nairobi said a total of 37 findings are expected in the report, 35 of which will have "direct relevance" to Kenya Airways.

The 114 people on board came from 26 nations, including an American AIDS expert who worked at Harvard University; businesspeople from China, India and South Africa; Cameroonian merchants; a U.N. refugee worker from Togo; and Briton Anthony Mitchell, a Nairobi-based correspondent for The Associated Press.

The investigation into the crash has been a long and difficult process. The plane went down in a mangrove swamp less than 6.5 kilometers from the runway, but it took officials 40 hours to find the plane. It took officials weeks to identify remains and there was a further delay before Cameroonian authorities released them to next of kin.

The wreckage indicated the plane flew nose-first into the ground. It was found buried deep in a crater of reddish-brown muck with only tiny bits of the rear fuselage and wings left above ground.

As a report into the Kenya Airway’s crash in Cameroon 2007 was released on Wednesday, it emerged that the lapse on the part of Kenya Civil Aviation Authority (KCAA) may see the national carrier pay higher insurance premiums.

Findings of a report of the crash indicate that chances of the crash occurring could have been averted, or significantly reduced, if Kenya Airways implemented its accident prevention system properly.

"KCAA failed to point out that Kenya Airways did not take into account the inefficiencies of the captain and the co-pilot during their evaluations by the company flight instructors," said the report.

"A number of operational procedures listed in the company’s operational manual were deviated from by the crew..."

Key among the concerns include the waiver of experience requirement for some of the pilots even after KQ signed to become part of international air travel agreements in 2007.

Prior to the flight, KCAA had waived the need for the co-pilot to have an experience of at least 150 flight hours, and three months of flight experience as laid down in the Kenya Airways operational manual provided by KCAA in line with international agreements.

"A waiver for requirement for utilisation of Flight Operations System had been introduced to satisfy operational demand," the report shows.

"These waivers were granted without adequate study on its safety implication."

Following the publishing of accident report, Kenya Airways is now staring at huge insurance premiums to cover its customers against accidents following revelations that the airline’s flight 507 crash had an element of human error. This move is likely grow the airline’s expenses and reduce profitability.

Experts say that a worst-case scenario may see Kenya Airways pay directly for compensation claims if the insurance provider cites the negligence clause on the part of the national carrier.

"If there is an element of human error as the report says, Kenya Airways may be in big trouble as it may be interpreted as negligence on its part on staff training and duties," said Peter Simani, an aviation lawyer.

"Another scenario is that of higher insurance premiums in future negotiations due to perceived risks as a result of the findings," he says.

Reports, pointing a laxity in implementing regulations due to personnel issues that should be addressed at Kenya Airways.

"KCAA will have to be strict in providing an implementing schedule as to how airlines recruit, train and promote their pilots and co-pilots but at the same time extend such programmes to their cabin crew," said Mr Simani.

Complete report;

http://www.ccaa.aero/images/blogs/d0...rt%20kenya.pdf
http://busybee.dvv.org:8000/flying/rapport%20kenya.pdf

[David K-M]

Several paragraphs in that tourismandaviation.com report look oddly familiar (http://www.flightglobal.com/articles/2010/04/28/341192/kenya-737-crash-poor-airmanship-led-to-disorientation.html)... :suspect:

[wilyflier]

OK lets have it someone,
What was the crew training background, and nationality?

[Skylion]

Kenya Airways originally intended to temporarily employ foreign contract pilots to assist them through their period of rapid growth. This was rejected by the pilots' union, KALPA.

[Go Smoke]

Why on earth are people still dying like this. Disgraceful.

[safetypee]

I am interested in the similarities of this accident with that of the ‘Flash’ 737.
What was the aircraft instrument fit – EFIS; dials vs strip speed.
Are all the aircraft in the fleet similarly equipped?
When did the Airline / Crew convert to this instrument system

[Sqwak7700]

What was the aircraft instrument fit – EFIS; dials vs strip speed.
Are all the aircraft in the fleet similarly equipped?
When did the Airline / Crew convert to this instrument system

That is all irrelevant SafetyPee. This accident (like many recently) was caused by a lack of the fundamental skills that pilots should have nailed down by the time they have their instrument rating. It would be the equivalent of a surgeon not knowing how to scrub his hands properly before entering the OR, or a Chef not knowing how to make you an omelette.

You have no business in the cockpit of an airliner if you don't know how to:

- Fly on instruments
- Recover from an unusual attitude
- Properly manipulate the automatics

It is unfortunate, but this is what happens when you put commercial interests in front of safety concerns. Regulatory authorities are there to prevent corporate greed from putting passenger's lives at risk. In my view, the Kenyan regulatory authority is just as much to blame as Kenya Airways.

We need to make regulators responsible when they lower safety margins and an accident occurs. Otherwise, the situation won't ever change. Don't mean to pick on Kenya, this is happening all over the world as profits get bigger and will get worse with the continued decline of pilot numbers.

[cactusbusdrvr]

It also sounds like an over reliance on the automation. If you have an excessive bank angle the autopilot is not going to save you.

It's what you should learn in the first hours of flying - Fly the airplane first. Sort everything else out after.

[Arkroyal]

Haven't got time to trawl through whole thread, but I seem to remember that the Capt was ex military, accustomed to russian made fighters in which the horizons work opposite to western design, i.e. the airplane symbol moves around a fixed horizon.

If so, would explain inputs from Cap opposite to required, and conflict with cojo.

If not, I'll get me coat.

[rcsa]

The Kenyan Airforce has never flown East European/Soviet types. It has recently bought a handful of Chinese Harbin Y12 transports and Z9 choppers, but if the Capt had been with KQ for over 20 years he would only have flown Western types.
In fact, this accident is further evidence of a systemic and highly worrying lack of competence at KCAA, an organisation that is obsessed by following the letter of their hugely over-written bureaucracy while ignoring the intent and sense.
And of course, in the past few years Kenya has become one of the most endemically corrupt countries in Anglophone Africa.

[Swiss Cheese]

On rotation the aircraft had a tendency to roll right. Captain maintained wings level by input of 30 degrees of left control wheel. Boeing talk about 6 degrees left control wheel to counter structural deviation.

So, why did the Captain have to input 30 degrees of left control wheel to keep the bank angle within the 3 degree limit? I do not blindly accept that rudder trim made up the difference somehow.

Also, only the boxes were taken from the wreckage, and everything else was left to be looted. There were suspected spoiler retraction issues with the SF version, and nothing in this report touched on this issue.

Thoughts?

[kotakota]

Yes , I was one of the intended LTCs needed by KQ 3 years ago , but rejected by KALPA ie strike threat , just wanted a 1 year contract , hopefully renewed if I was doing my job satisfactorily . Looking forward to ending my career where it started and giving something back , just wanted a fair wage .
Still love Kenya where I spent the first 28 years of my life , very disappointed that I was rejected out of hand .Not for me to say , but there has to be something unmentionable going on here ?

[safetypee]

Sqwak7700, Re #369.
I don’t exclude those contributions which you list; there are many others. However it could be short sighted to exclude other aspects which, although appearing to be irrelevant, might have contributed to this accident or should be consider in avoiding a future accident.

A significant contribution appears to be mis managed attention, perhaps due to over focus on weather radar and the avoidance of storms.
It could be possible that some EFIS formats or the crew’s unfamiliarity with them, contribute to reduced attentional resources, e.g. if strip speed formats require greater concentration than a dial presentation or the crew has recently changed to strip speeds, then the crew might not appreciate the change in workload. Similarly with any change FMA location.
It is often the small and seemingly innocuous changes in operating situations which lead to error.

Re:-
Pilots are taught to fly on instruments; but are the techniques / skills used in manual flight the same as those when the autopilot is used; what changes, when, and why.
Pilots should be able to recover from unusual attitudes; however, this assumes that the abnormality has been identified and correctly interpreted, particularly when suffering acceleration based disorientations. Disorientation is a significant hazard – it is difficult to identify and all crew can be affected simultaneously.
Pilots should be capable of operating the aircraft systems correctly, but due to human limitations and weaknesses, we all make ‘small and irrelevant’ mistakes; except that the relevance depends on the context of the situation which also may have been misjudged and then these errors become potential contributors to accidents.
I would agree that the conjunction of a weak crew and an adverse situation was central to the accident, but the basis of safety in our industry depends on defenses in depth which mitigate the extremes of these hazards. Thus, the interesting issues might be why these safety nets apparently failed.

[mejjammm]

Food for Though..

· Why was the conversation btwn the captain and FO btwn Abidjan and Doula censored from the report?
·Why was the heated argument in the Yaunde Air Control tower btwn 2 air controllers on whether to clear the aircraft for take off or not under that stormy weather condition censored?
·The net tendancy of the A/C to roll to the right was not addressed fully in the report, was it a technical default ? was it a production malfunction?
·Prior to such incidences was it a requirement for the FO to verbally respond to the OK “COMMAND”?
·If the Captain initiated the engagement of the AP then why “ did it not engage”
·Did the AP disengage ? If so why was this not documented?
·Per earlier conversation the captain requested TWR that after takeoff they wanted to head right due to the weather condition ahead. Did the tendency of the A/C to bank right dissolution the crew into thinking that the AP was still engaged?
·Do 737-800 APs disengage under stormy conditions?
·Why didn’t the report mention pilot error as the cause of the accident but human factor?

[dvv]

mejjammm, the report clearly address the slight tendency of the aircraft to slowly roll when left to its own devices, see part 1.16.1. Airplane Performance; subpart B) Lateral Trim of the B737-800. Also, the report is convincing enough as to the reason for the AP's not engaging, see part 2.2.3.1, the third bullet point. Either way, please move the conspiracy theories to Jet Blast (http://www.pprune.org/jet-blast-16/).

[jcjeant]

Hi,

mejjammm (http://www.pprune.org/members/327210-mejjammm)
You don't read enough PPRuNe forums .. otherwise you had understand
No conspiracies theories are admitted here.
No politics linked theories are permitted here.
In fact .. some wonder if rumours are permitted here.
Officials reports are here granted to be exact and true and can't be discuted.
So never write "coverup" or "Conspiracy" :)

[Re-Heat]

The report noted that the captain was 52 but that the first officer was only 23. Before takeoff the pilot admonished his first officer for turning on the plane's windshield wipers, and the report speculated that the first officer, already a shy person, did not speak up to tell the pilot about the aircraft banking when he should have because of their relationship.
Total CRM failure then. Have we not learned from the BEA Trident crash at Staines? What total lack of rigour allows these cockpit cultures to develop?

Age is irrelevant; cockpit culture is the failure here.

[keitaidenwa]

.: Capital FM Kenya: For Breaking News in Local, International, Business, Sports and Lifestyle :. (http://www.capitalfm.co.ke/news/Kenyanews/Kenya-)
Airways-faults-2007-crash-report-8281.html

KQ agrees with report except for three minor details:

1. Auto pilot engagement

Unlike what the report says, the KQ insists that their SOP requires confirming autopilot engagement.

2. Safety Oversight Capacity

KQ complains that the report has conflicting opinions if KCAA if had or had not enough safety oversight.

(I agree with rcsa regarding with overbureacracy of KCAA, but that was not a contributing factor to this accident).

3. Crew Resource Management Training

KQ complains that the report has conflicting information if the first officer had went through CRM training.

Full statement from KQ :

http://www.capitalfm.co.ke/news/downfile.php?downId=48

IMHO Kenya Airways doesn't adequatly explain in the response how they have changed to ensure Douala and Abidjan accidents won't happen again. They emphisize that Kenya Airways has gone through IATA Operational Safety Audit (IOSA) and thus must be safe. But KQ was already through IOSA when Douala happened!!:ugh:IOSA seems not much more than a paperwork excersize.

To the credit of KQ and the Kenyan media, they have not gone to the loony theories like flash airlines 604 or Egyptair 990.

[Frangible]

Why has there been so little comment on failure to request take off clearance?

Previous poster. If that's credit, then God help us all.

[PEI_3721]

The operator has identified actions broadly in line with the report’s recommendations, but what else can the industry, operators, and individuals, learn from this accident. These points shouldn’t concentrate on curing the aspects specific to this accident, but should also consider related or generic issues which might lead to a similar accident in the future.

Several postings list alternative contributing factors, some have glib statements of cause, but few if any provide solutions to avoid this type of accident.
The recent accident record due to ‘loss of control / disorientation’ suggests that we haven’t learnt much over that last 4-5 years. Thus what can we learn now; what must we learn and how can safety be improved from these aspects?

I am reminded not to rush when engaging the autopilot, and after selection to check for correct engagement and the selected mode operation.
Before engagement confirm that the aircraft is in trim and no stick force is being held – like you, the autopilot does not like out of trim aircraft either.
These require self discipline, conscious thought and effort, all at the root of airmanship.
How can airmanship to be improved – a mixture of knowledge, habit, example, review, and memory, and with honest self criticism just to start with … but then we don’t always have good days.

Contributions?

[Whenwe]

I am deeply disturbed about the cause of this and other accidents. I remember the days when having a RMI was heavenly. A Flight Director ......wow!

We started digging this hole (sorry no pun intended) years ago.
If we are honest with ourselves, we need to ask if we can handfly the aircraft and comply with the accuracy that is required nowadays.

Otherwise; simply add the following to the 10000 ft checklist climbing and decending: Autopilot.... Engage / Disengage.

Take care out there.

[Capt Chambo]

Haven't had a chance to read the report yet.

This article appeared in "Flight" a few months ago. Combine it with recent threads about Airline Pilot's lack of manual flying practice and modern training programmes it makes for prophetic reading.

Pilot disorientation accidents have become a phenomenon (http://www.flightglobal.com/articles/2010/01/29/337743/pilot-disorientation-accidents-have-become-a-phenomenon.html)

[mejjammm]

D.V.V.
Quoting the pargraphs you outlined

1.16.1 - Consequently ,It is established that at TO from Doula , the airplane has a tendency to roll to the right due to the combined effects of the inherent assemtry from construction and the slightly right position of the rudder trim. To counter this roll tendency , some effort should be exerted to maintain the control wheel turned about 8 degrees to the left




2.2.3 -Bullet 2 -Then the captain calls "OK CMD" to engage the AP;he then behaves as though the AP is effectively engaged, something which is neither confirmed by announcement by FO,nor by the FMA , nor by the behaviour of the airplane itself.On the other hand , the automatic activation of the speed trim following excessive increase of speed could contribute to sustain his false impression of the AP being engaged.

2.2.3-Bullet 3 -There is no evidence why the AP didnt engage but the DFDR data incates a slight control column pressure as "OK Command" call is made by the captain.There is a possibilty that the selection was selection was made but the pressure on the column interfered with engagement of the autopilot. It should also be recalled that the AP"CMD A " had suffered recurrent breakdowns for a period of three moths prior to this flight.This leaves us with more questions than answers-

Why are parts higlighted not included in section 3.2. probable causes -This in hand are major contributing factors in the accident -If they are addressed then such accidents can be avoided in future.
Can we speculate that there are other sources responsible for the accident ?

On Establised Facts items 34 & 35 are not deeply covered as the other items in the report , why? and their weigh in the cause of the accident is equivalent to the others

34- Information to crews was missing on the rolling tendency of the airplane during climb and descent and the elements that induce it including a) Rudder Thermal effect . b) Manufacturing asymmetry

35- Full information in the capability of the Autopilot CWS roll mode including ability to roll the airplane from bank angles of 50 degrees and above to 30 degrees bank is not explained in the Boeing Flight Manual

[Northbeach]

Must admit I did not know about the thermal expansion of the rudder leading to the rudder deflection issue brought up in this report.

According to this report we are looking at a maximum .75 (3/4 of a degree) deflection left or right, or one and a half degrees total (1 ½) due to this phenomenon. No temperature data was given along with the ¾ of a degree off center figure. I have closed the report so don’t have the data in front of me. I don’t think the aircraft gained more than 3,000 feet AGL. Given the standard lapse rate we are talking less than 6 degrees temperature differential between the airport and the maximum altitude gained. So there cannot be much temperature change involved in this accident.

And, how long was it from rotation to impact? In this accident little time elapses from rotation to impact. Our temperature change is very small and our time frame is also very small. So, how much did the ruder deflect due to “thermal expansion” on this particular accident? Given my limited exposure to this “Rudder Thermal Expansion” phenomenon I would say precious little if any. Interesting academic exercise and information, but I doubt if it has any relevance to this accident.

This aircraft having an inherent tendency to roll to the right sounds menacing. The wording sounds like somebody is laying the ground work for a lawsuit against the manufacturer and/or airline for having a “killer airplane” loose on the public. Now if you take your hand off the beast and it rolls over on its back, we have an issue. If we are talking about a low, single digit 1-2-3 degree, roll to the left or right that would be a fairly routine occurrence. How many airplanes with the yaw and roll trim set at zero would stay perfectly in trim for any significant amount of time if you took your hand off the controls? In my world – none, and we fly over a hundred 737 airframes.

“Thermal expansion and deflection of the rudder” was an interesting technical point of this report. However I do not believe it has any bearing of this accident.

Mentioning the aircrafts tendency to roll to the right also has little to do with the cause of this accident.

I was impressed by the frankness and quality of the report. That reflects well on the issuing agency. I have no inside information, nor do I have any professional contact with any of the parties involved, I just fly the same model. Like many of you I have been waiting for the official report.

On a closing thought, it is sobering to have the comments recorded in one’s personal dossier made public. In this case the Captain’s shortcomings; CRM, systems, SA, performance and technical training failures highlighted several times.

[A37575]

* Pilots are taught to fly on instruments; but are the techniques / skills used in manual flight the same as those when the autopilot is used; what changes, when, and why.
* Pilots should be able to recover from unusual attitudes; however, this assumes that the abnormality has been identified and correctly interpreted, particularly when suffering acceleration based disorientations. Disorientation is a significant hazard – it is difficult to identify and all crew can be affected simultaneously.
* Pilots should be capable of operating the aircraft systems correctly, but due to human limitations and weaknesses, we all make ‘small and irrelevant’ mistakes; except that the relevance depends on the context of the situation which also may have been misjudged and then these errors become potential contributors to accidents.


Then why aren't Boeing 737's continually crashing all over the world if pilots are up against all those events you call up. You only have to be a simulator instructor to see such horrifying cock-ups by airline captains from various countries that you privately note NEVER to be a passenger with one of those operators. Why the head-long rush to engage the automatics immediately after take off? The Flash Air 737 crash was almost identical with the captain screaming for the autopilot to be engaged all the while the aircraft is spiralling in at 420 knots..

It is because airline pilots are getting more like trained monkeys, brain-washed by the manufacturers, the regulators and their airline ops management into avoiding hand flying like a plague. When you read the FCOM of one German 737 operator which that says "flying by hand is to be avoided unless under the most exceptional circumstances". You then know there is no hope for these idiots. This type of over-reliance on immediate engagement of the automatics is to be seen in most airlines now. This leads to laziness and complacency and finally total incompetence - with the inevitable final result we see in so many automation related crashes.

[Spadhampton]

It's almost as if they completely forgot how to fly.

Captain: “Are we crashing?”

Oh Please, these guys shouldn’t even have been allowed anywhere near that airplane!

[barit1]

Probably 5-10 years ago AW&ST had an article about the Canadian National Research Council with a Harvard configured with a "flexible" glass cockpit to evaluate various attitude displays. They invited guest pilots to test the displays in unusual attitude recovery - testing time to recognize the situation, and likelihood of applying the right corrective action.

Since my Dad once taught in AT-6's (Texan/Harvard) I'm sure he would have enjoyed the exercise. When students graduated, they were given the opportunity to put their instructors through a "hell ride" - and some of the students were better than their instructors!

See: http://www.nrc-cnrc.gc.ca/obj/iar-ira/doc/harvard_eng.pdf

[soullimbo]

The report noted that the captain was 52 but that the first officer was only 23. Before takeoff the pilot admonished his first officer for turning on the plane's windshield wipers, and the report speculated that the first officer, already a shy person, did not speak up to tell the pilot about the aircraft banking when he should have because of their relationship.
Total CRM failure then. Have we not learned from the BEA Trident crash at Staines? What total lack of rigour allows these cockpit cultures to develop?
Age is irrelevant; cockpit culture is the failure here.


BEA Trident crash at Staines... What about the biggest disaster ever in Tenerife caused by an arrogant KLM captain? 30 odd years on and history repeats itself. The unfortunate thing is that this airline is part-owned by KLM.

[Oakape]

From another thread -

Article published in a UK magazine. Relevant to the subject of the opening post on the Kenya Airlines B737-800 crash.



George Has Control - or has he?

Once known as ‘George’ the autopilot has come a long way since the first one flew in 1912. But has an over-reliance on automatic systems degraded many pilots’ basic handling skills? .

. The Jeppesen ILS approach chart was for Noumea Runway 11, New Caledonia, ICAO designation NWWW. The MSA to the north-east is 7000 ft and to the south 5500 ft. An NDB, callsign NW, is on the extended centerline 8 miles from touchdown along with another NDB and VOR at the airfield. Following the recommended procedures published in the Boeing flight crew training manual, the crew made full use of the automatic pilot systems. As the aircraft turned to final approach a fault occurred with the No 1 engine thrust lever clutch motor. Thus, when the automatics commanded a thrust increase to maintain a set airspeed, the throttle lever of that engine would not move from the last setting prior to actuation of the fault. The last setting was throttles closed idle thrust. Manual throttle operation was not affected.



The autopilot was programmed to descend the aircraft to 1800 ft until intercepting the glide path. The captain called for the flaps to be extended to slow the aircraft to approach speed and the first officer set the correct speed for the flap setting into the autothrottle mode control panel. As drag from the landing gear and flap extension took effect the autothrottle system increased power to maintain the demanded airspeed but because of the autothrottle defect only one throttle moved to increase power.

With a large split between the throttles, the autopilot tried to compensate by using a combination of aileron and spoiler controls to maintain directional control. At this point both pilots were concentrating solely on monitoring the autopilot mode status, unaware of the asymmetric thrust and the steadily increasing control wheel angle. The landing check list was being read when the automatic pilot suddenly disconnected accompanied by the aural disconnect warning. Unconstrained by the autopilot, the aircraft rolled rapidly beyond 45 degrees, and losing height below the glide slope. By now the GPWS below glide-slope warning sounded and it was then for the first time the crew saw the marked difference between the throttle settings.

Observing the No 1 (left) throttle was against the idle stop and wrongly assuming the engine had flamed out, the captain called for the engine failure and shut down checklist. The first officer hurriedly reached down to locate the Quick Reference Handbook (QRH). Still scrabbling to find the right page, he never saw his attitude direction indicator (ADI) hard over beyond 60 degrees of bank and the altimeter winding down in a blur. In real life, a searching helicopter would have located wreckage at a position five miles from the airport and a quarter of a mile to the north of the ILS inbound track. There would have been no survivors. At the time of estimated impact the simulator made a loud graunching noise and the windscreen turned red with simulated blood (a macabre modification by the technicians to the windscreen view to signify Heaven’s open door. So great was the impact, a re-boot of the simulator was necessary.
Modern airliners are equipped with superbly reliable automatic flight control and navigation systems. And certainly the remarkable reduction in CFIT over the years, attest to this. Yet there is a downside. One sage pilot described this perfectly when he said that automation robs situational awareness through absence of physical/sensory cues of flying the machine and as a result atrophies flying and thinking skills. He added that when automation degrades it can overwhelm even a highly competent well-trained crew. Other than that, automation used as intended - and not as an aircraft babysitter - was a tool for accuracy, predictability and timeliness of action.

Automatic throttle control systems have featured in several fatal crashes. In 1992, a China Airlines Boeing 737-300 crashed 15 miles from its destination. During the visual approach, with the autopilot and autothrottle engaged, the left thrust lever advanced while the right one remained at the idle position. The crew apparently failed to notice this asymmetrical power condition and allowed the aircraft to roll into a spiral dive.

Three years later in 1995, an Airbus A310 crashed in a steep nose-down attitude three minutes after take off. According to the accident report, the crash apparently resulted from a malfunction in the aircraft’s autothrottle system when power was reduced from takeoff to climb thrust. Mechanical jamming of the right throttle resulted in this engine remaining at full-power setting, causing an asymmetrical thrust condition that led to loss of control. The crew was slow to recognize the malfunction, which occurred over a period of about 40 seconds beginning when the aircraft had reached 2000 ft and continuing after it was cleared by ATC for a left turn. During this turn, the left bank steepened, with the Airbus over-banking into an 80 degree spiral dive and 290 knots before impact. Recommendations issued by the French Director General of Aviation in the wake of this accident, included the careful monitoring of throttle behaviour when the autothrottle is engaged, and its immediate disconnection and reversion to manual control if a malfunction occurs. Of course that was only saying the bleeding obvious, but crashes due to crew mishandling still occur.

In 1998 another Airbus crashed. This time at Taiwan, during a go-around from a high approach. Instead of disconnecting the autopilot when it was apparent that it was not coping quickly enough with thrust changes, the crew persisted with autopilot operation only to stall the aircraft due to an excessive out of trim situation, killing all aboard. Four years earlier an almost identical crash had occurred at Nagoya, Japan where investigators determined an extreme out of trim condition caused the aircraft to pitch up uncontrollably until it stalled.

In 1985, a China Air Boeing 747 flying at 41,000 feet over the Pacific in cloud and in moderate turbulence, experienced an autothrottle defect that caused one throttle to stay at idle thrust. Initially, there was no action taken to turn off the autothrottle system and adjust the power manually. In spite of having several minutes to act, the pilot failed to control the yawing moment and the 747 rolled inverted into a spiral dive. It reached Mach 1.0 and 5g, losing 30,000 feet before recovery was made below cloud at 9000 feet. .

Fast forward to 2009 where a Flight International headline reported Thomsonfly stall pinned on autothrottle.. No one was hurt when in September 2007 the Boeing 737-300 came close to stalling during a night ILS approach to Bournemouth airport, UK. The autopilot and autothrottle had been engaged at the start of the approach. However, an undetected malfunction caused both thrust levers to stay closed instead of holding approach power with flaps down. The crew did not notice the subsequent loss in airspeed as the autopilot tried to hold the ILS glide slope. The captain conducted a belated go-around with the aircraft reaching a pitch attitude of 33 degrees and speed of 82 knots before he was able to get the situation under control.

Not so fortunate, was Turkish Airlines Boeing 737-800 Flight 1951 that crashed in February 2009 during an ILS approach to Amsterdam. A defective radio altimeter fed wrong information to the autothrottle system causing the throttles to close to idle thrust. Like the Bournemouth incident, the autopilot tried to maintain the ILS glide slope by pitching up and trimming back. For over a minute the crew noticed the throttles were closed yet apparently failed to take corrective action until too late to prevent the aircraft stalling into a field, killing several passengers and crew members.

In most of the cases mentioned, prompt action by the crew to notice the worsening situation followed by immediate action to disconnect the automatic pilot system and fly the aircraft manually, may well have prevented each accident. As one pilot warned “Do you control the automated cockpit or does it dominate you?” While aircraft manufacturers encourage full use of automation, it is surely with the unspoken caveat that if automation is distracting your flight operation, early intervention should prevent things from getting out of hand. The Boeing 737 flight crew training manual covers this by recommending reduction of the level of automation as far as manual flight, to ensure proper control of the aircraft is maintained.

That last paragraph,” reducing the level of automation as far as manual flight” reveals the importance placed by manufacturers - and indeed airline operators, on the flight safety value of auto flight systems. Yet, the countervailing argument that manual flight skills are just as essential as automation is rarely mentioned in official manuals.

Perhaps a similar misguided philosophy led to the death of all 112 on board when an Adam Air Boeing 737-400 crashed into the Makassas Straits off Selawisi Island, Indonesia. The accident summary said the cause of the accident was failure of the pilots to monitor their flight instruments while trouble-shooting the navigation system. While in cloud, the automatic pilot disconnected as the crew were engaged in discussion of an apparent defect in the inertial navigation system. Unnoticed by either pilot, the 737 gradually entered a steep spiral dive. When the penny dropped, and the captain realized his aircraft was rapidly getting out of control, he made matters worse by pulling back hard on the control column instead of using the correct procedure for recovery from an unusual attitude. The aircraft broke up in the air.

We need a happy ending for a change, so you are invited to contrast the actions of the ill-fated Adam Air crew with those of a Mystere 20 Falcon crew faced with an unexpected runaway stabilizer electric trim on short final to runway 16 at Sydney, NSW, Australia. This is an edited extract from the Bureau of Air Safety Investigation of the incident. Keep in mind, the aircraft was flying over built up areas immediately surrounding the airport because this report will make your hair stand on end. The captain had 14,100 flying hours experience while the copilot had 8000 hours.

Following a normal flight the aircraft was established on final approach for landing. At about 140 feet above the ground, the approach angle flattened and the nose pitched up. The co-pilot, who was flying the aircraft, believed that a wind-shear situation had been encountered, and he initiated a go-around. As full power was applied the nose pitched up violently. The crew did not observe any cockpit indications as to the reason for this reaction.

The pilot in command took control of the aircraft and initiated a rolling turn. This had the effect of reducing the pitch angle, and by manipulating power levers and rolling, the pilot was able to regain control of the aircraft at about 6500 feet. A safe landing was subsequently carried out. Witnesses later reported that they observed the aircraft had reached pitch and bank angles of 60 and 40 degrees respectively. Because there had been no indication of the cause of the initial pitch up, the crew had difficulty in determining the appropriate course of action. Although the investigation revealed the initiating factor was probably a full nose-up trim situation, the crew believed the problem was caused by a structural failure or a thrust reverser malfunction

This brief official description of the incident did not tell the full story, however. In his report, the pilot stated (edited for brevity): At 140 feet above runway 16 the copilot stated that things were wrong and he was going around. Power was applied and loss of pitch control followed immediately. I took over control of the aircraft and I can still recall the IAS drop below 107 knots. I had both hands holding the control column fully forward trying to limit the rearing of the body angle. My concern was that we were going over on our back which would have been the end, as this manoeuvre started at about 80-90 feet AGL. In my mind was that the vertical lift of the aircraft had to be minimized so I rolled it to the left in a very steep turn and had the copilot close the throttles to assist me in getting the nose of the aircraft to come below the horizon. This turned out to be successful and we recovered prior to ground contact. As power was restored the nose pitch attitude reached again the 60 to 80 degrees (as some witnesses in the control tower claimed)

During the first go-around the flaps and gear were retracted and we did a series of the above manoeuvres, using roll and power off and an application technique as described above, each time gaining some height above ground level although we had very limited heading control. We did this for about 5 or 6 times and obtained about 6500 feet AMSL During this time I was unable to take either hand off the control column or relax the force required to limit the rear of the body angle. The copilot was completely occupied with the closing and opening of the throttles to help me semi-control the nose position. The aircraft eventually flew out of the problem and returned to normal operation with no further input from the crew.

Once the first recovery had been achieved I knew that I could control the aircraft to a certain extent whilst the fuel lasted. This could not have been possible without the excellent crew co-ordination between PF and PNF. A help to me was the knowledge of aerodynamics instilled by instructors during my early training on Tiger Moths.

During the technical investigation of the incident no fault could be found in the stabilizer actuator although another fault which was considered responsible may have been intermittent in nature. The captain of the Mystere Falcon exhibited superb airmanship in recovering the aircraft from a deadly situation and if a military pilot would no doubt have been recommended for the award of the Air Force Cross. This was pure flying skill at its best.

But all that happened many years ago. The game has changed since then, and now we have the situation almost world-wide where low cost airlines recruit low experience pilots as second in command of large airliners. While this may be partly due to a perceived shortage of experienced pilots, it is more likely aimed at cost-cutting where pilots are willing to pay for their own training on passenger jets. It is common to see newly graduated commercial pilots self funding a type rating on a Boeing or Airbus. Next thing is to find an airline happy to offer them a first officer position. No problem there, with agencies keen to place them (at a price, of course) with an airline willing to hire them in the right hand seat for six months. Captains are expected to look after the new boy or girl by giving them take off’s and landings in fair weather as the youngsters build up their jet hours to qualify for full-time jobs.

Because of the low experience of many new first officers, it is with some relief their mentors can plug in the automatics from take off to landing and sit back and relax while the first officer merely monitors the automatic pilot on his leg. With airline policy dictating the full use of automatics during revenue flying the exposure to the real world of manual flying for skill retention, is neatly side-stepped.

In this article we have read of fatal accidents caused by crew mis-handling the automatic systems – particularly while flying at night or in IMC. Statistics reveal Loss of Control as the new major cause of aircraft fatal accidents. This was highlighted during a recent Asia Pacific Airline Training Symposium held in Hong Kong where the Airbus representative urged the aviation industry to confront the issue of how to ensure long-haul pilots maintain basic flying skills in the face of ever-increasing aircraft reliability and cockpit automation. “I think that at a certain point in time we need to bring back a little bit of handling”. He advocated more simulator time for pilots to hone their basic skills. “We put people into our training today who have forgotten how to fly, basically” That would surely be the understatement of the year.
Of course not all pilots have forgotten how to fly. But consider this true story of a 2000 hour newly recruited first officer at the controls (on automatics, of course!) of a Boeing 737. With the airport in sight at 15 miles, the captain suggested it would be a good opportunity for his Number One to disconnect the automatics and fly by hand. This perfectly reasonable suggestion was met with a shocked look and shaking of the tousled head as the first officer said no way was she going to hand-fly when the automatics did a better job – passenger comfort and all that jazz. Now it was the captain’s turn for the shocked look and shaking of head. Another time, a keen first officer asked his captain if he (the first officer) could turn off his flight director during a VMC climb so he could practice raw data manual flying. The captain refused; saying, leave that to the simulator.

While some of the more enlightened operators permit manual flying in appropriate airspace and weather conditions, others discourage it. A regional operator in Australia flying turbo-prop commuter aircraft insists crews use full automation from after lift-off to short final even in CAVOK conditions, leading to the ridiculous situation where furious knob twiddling of the autopilot takes place as the aircraft tracks from downwind to base and final in the circuit area. These are the same crews that eventually move up the food chain to fly the big jets. The regulator doesn’t mind one bit as long as rules are not broken. .

The reality is that manufacturers and airline operators will not venture from their comfort zone and encourage pilots to hand fly at their discretion. Some captains will quietly encourage a spot of manual flying here and there – flight directors on, of course. No point in stretching the friendship too far, they say. One captain interviewed observed that automation complacency is so well entrenched that many pilots politely decline his suggestion they hand fly on raw data occasionally –even if a recurrent simulator session is getting close. A few months ago, a Boeing Company check pilot talked to pilots of a major Hong Kong-based airline. In his travels, he noted that some airline pilots tended to avoid the opportunity to practice hand flying skills until the very last minute before a simulator session. This was a waste of time, he said – because manual flying skills had to be maintained throughout the year and that a hand flown ILS in good weather after months on autopilots, did nothing for basic flying skills.

Following the UK report on the near stall of the Thomsonfly Boeing 737-300 mentioned earlier, Flight International quoted a CAA observation that: Pilots familiar with operating older aircraft, which had more variable reliability, are nearing the end of their careers, and there is a generation of pilots whose only experience is of operating aircraft with highly reliable automated systems.” The writer maintained that exercises mandated in recurrent training programmes have scarcely changed since the days of the Super Constellation. So training no longer represents what crews are likely to have to deal with today.

The solution is change the mind-set of regulators and operations departments. While Loss of Control accidents will never be eradicated, training departments should learn the lessons of past accidents and apply them to more realistic simulator training. Normally in recurrent simulator training, each crew member can expect two hours per session as pilot flying. Over a 12 month period this amounts to at least eight hours of handling per year depending on the number of sessions scheduled. Most of these sessions in the simulator will be on automatic pilot, with occasional manual flying to meet regulatory requirements. One engine inoperative flying forms a good proportion of each simulator session and much of that is on automatic pilot. This does not leave much time for practicing raw data pure flying skills. That policy must change if airlines are serious about learning the hard earned lessons from past accidents.

While LOFT exercises are valuable for practicing CRM skills, they rarely provide manual handling practice. Valuable simulator time is sometimes wasted in lengthy LOFT scenarios that require complex checklist use and associated crew discussion. Often the pilot finds he has done only two landings by the end of the session. To ensure a high standard of manual flying skills are maintained throughout the year (not an unreasonable expectation), simulator sessions should be scheduled to allow equal time between automatics and raw data manual flying. If that is a problem then additional time should be scheduled. Simulator training might be expensive but peanuts compared to the cost of a crash such as those described above.

Pilots should be given the opportunity to practice raw data hand flying in sequences covering high and very low altitude stall recovery, circuits and landings in strong crosswinds, unusual attitude recoveries, GPWS pull up manoeuvres, bad weather low level circuits, forced landings following loss of both engines, flight on standby flight instruments, instrument approaches general and all flaps up landings on limiting length runways. Additional sequences could include black-hole approaches over terrain devoid of ground lighting, and slippery runway short field landings. For the purpose of all these exercises, the automatic pilot, autothrottle and flight directors should be left off. To keep these pure flying sessions within reasonable time limits, the instructor should use the freeze and re-positioning facility of the simulator as well as common-sense reduction of QRH and checklist reading. Keep in mind the aim is to allow the pilot the opportunity to practice basic handling skills within the time constraints of simulator scheduling.

Earlier, mention was made of the superb skill and airmanship displayed by the captain of the Mystere 20 Falcon at Sydney, in recovering from a series of extreme attitudes caused by a stabilizer trim malfunction. He attributed this skill to lessons instilled into him by his instructors on Tiger Moths. Who knows that one day in the future, a pilot recovering from a one in a million jet upset in a highly automated airliner will thank his simulator instructor for teaching him the art of pure flying.

[etherate]

This was certainly a fascinating report. I too, like some other posters, had also never heard of the rudder thermal expansion issue, despite having been on 73s for some 15 years. One immediately wonders if there will be parallels with the Ethiopian 737 crash out of Beirut. Certainly has all the hallmarks (without of course jumping to any conclusions or cast any aspersions about the crew of that aircraft).

I agree that the takeoff without clearance was symptomatic of a lot of what was going wrong in that flight deck from even before taxy. Lack of proper crew coordination, fixation on expected poor weather to the exclusion of everything else.

What I thought was particularly interesting and may well send ructions through the industry, was the emphasis on crew training and performance records. Hidden in there somewhere was a gem about [crew] "pairing". Just wait til the lawyers get hold of that !
It is in a similar vein to the Helios report where two (shall we say, say fairly weak) individuals were "paired" together, and when the right circumstances all came together a disaster ensued. It does not make good reading for KQ.

Is it going to put pressure on airlines to be a lot more hard-nosed about persistent under-performance? All credit to KQ for having the sufficiently well documented training records for the investigators to find all this information. I can think of some companies where the training records may not have been so forthcoming.

This accident really does put loss of manual handling skills right back up there at the top of the debate.

[misd-agin]

1. 737 has tendency to roll to the right. It's similar to the amount of roll you'll find in any a/c on takeoff(which could be left or right) except that it's almost always to the right on the 737.

2. A/P engagement is very sensitive in the 737-800. Almost any control column pressure will prevent A/P engagement. Nothing new there for anyone that flies the a/c.

[Spadhampton]

There was nothing wrong with this aircraft. NOTHING!

Except incompetent pilots. Very plain, very simple.

[actros]

yes he did

[CaptainSandL]

Spadhampton,
Very plain, very simple - but also very harsh of you.

The same accident has now befallen the Kenyan, Flash Air and probably Ethiopian 737s within a few years. It is not just a third world malaise, I have seen it happen several times with British crew and I see reports of it happening to UK carriers several times a year. Due to the design of the 737 it is easily over looked. It is probably ending in tragedy more often these days because crews are more reliant on automation then they were 40+ years ago when the type was designed.

PEI_3721 had it right at the top of the page:

I am reminded not to rush when engaging the autopilot, and after selection to check for correct engagement and the selected mode operation.
Before engagement confirm that the aircraft is in trim and no stick force is being held – like you, the autopilot does not like out of trim aircraft either.
These require self discipline, conscious thought and effort, all at the root of airmanship.
How can airmanship to be improved – a mixture of knowledge, habit, example, review, and memory, and with honest self criticism just to start with … but then we don’t always have good days.

[Romeo E.T.]

the little "push button" autopilot engage switch on the newer generation on B737's requires one to look at the FMA to confirm engagement, not so with the older B737-200's and 300's where the paddle has to be engaged positevely into the magnetic lock....there is no doubt as to if the autopilot has engaged or not.....possibly something to look at in future designs of the B737 MCP....maybe going back to this older design woudn't be a bad idea.

[CaptainSandL]

Romeo ET - I totally agree.

[PLovett]

The PF should have been looking at the PFD as the PM engages the autopilot.

How much trouble is it to look at the top of the PFD to see if it has engaged before removing your hands? I'd say its worth about the lives of your crew and passengers.

[Slickster]

I've flown the 737 for more than a few years, although, I don't claim to be a "Greybeard". On a few occasions, I've thought I'd engaged the autopilot, and sat there, fat dumb and happy, wondering why the aeroplane wasn't doing what it was "supposed to".

The point is, if it ain't doing what you like, don't just sit there and watch it happen. Do something about it. That's why you're there.

[davecr]

Thats exactly why, in my airline, we can only say "autopilot A/B in command" after we have verified the FMA indication. Just pressing the button doesn't mean anything - the slightest bit of pressure on the control column means the AP will not engage. I would hope that other operators also follow this SOP?

:(

[CaptainSandL]

Davecr,

Your airlines SOP, whilst well intentioned, is at best a sticking plaster covering a latent threat and at worst just a**e covering. How many times have you, or have you flown with somebody, who will give you the standard response to a checklist item, because it is a habit? Eg “Seat belts … AUTO – oops no they are not, now they are”. We have all done it and just because there is an SOP to catch it is not a cast iron guarantee that it will not happen.

IMHO the best fix is a redesign of the A/P engage mechanism to give a warning if attempted engagement fails, eg the A/P disconnect wailer. This will be difficult to design & install. The most effective quick fix is to go back to the paddle engage switches which have tactile feedback if they are not engaged.

[filejw]

Sad..they say the cause is spatial disorientation but I wish the authority's were a bit more specific just so younger guy would learn....The capt was concerned about the TRW and i dont blame him and in a rush didn't make sure the A/P said command....so simple a mistake...look for the Ethiopian accident to be much of the same...

[Tee Emm]

I believe in the case of the Egypt Air accident where the captain was shouting for the autopilot to be engaged as a means of recovering from an unusual attitude (not a sensible thing to do as it turned out...), the CVR showed the F/O was in fact reading back to the captain using the words "God Willing autopilot engaged" In other words you would at first think he was telling the captain that the autopilot was indeed engaged. But it wasn't - at least not initially, anyway. The F/O merely repeated back a direction from the captain and this read-back possibly misled an incompetent captain into believing the autopilot was now engaged and he could take a deep breath and relax knowing his lack of hand flying skills would not be exposed. Unfortunately and tragically for everyone abord, they were exposed soon after.

[Romeo E.T.]

I fully agree with the statements regarding the paddle autopilot selector,

when in hard thunderstorm weather and heading out into pitch black darkness, the over-riding urge to get the autopilot engaged as soon as possible and go heads down to plot and plan around the severe weather is overwhelming, now with the old paddle autopilot selector it is very obvious to the pilot flying, under severe pressure to get it engaged, as to who is actually still flying the aircraft ie PF or "george" and until the autopilot paddle has latched magnetically. the PF would defenitely not loose control over the attitude of the aircraft as he is still in "command" of attitude/heading/speed etc,

with the newer autopilot selector the engagement is far to subtle, and in the "heat" of the moment of needing to get heads down and onto the radar etc it seems to have been shown on more than 2 occasions that the autopilot engagement was never accomplished, whislt the crew urgently diverted their attention to the task at hand of plot and plan around severe weather, thinking the autopilot was engaged.

it is all fine and well to talk of SOP's regarding the calls and the monitoring function around autopilot engagement sequence, but when faced with severe weather just after take-off, the crews mind is more focussed on avoiding weather safely, than being concerned if "all the i's have been dotted and t's been crossed" w.r.t. SOP.....and in these scenarios a tactile autopilot paddle engagement will defenitley relieve the pilot flying with rest assuredness that the autopilot is now in charge.....and even the Pilot non flying can see this due to paddle being held up and engaged.....no need to create a whole "broadway play of calls" to confirm autopilot engagement, and thus ...with respect Mr Boeing....the older system was beter.

[Tee Emm]

the over-riding urge to get the autopilot engaged as soon as possible and go heads down to plot and plan around the severe weather is overwhelming,

And that is precisely where the problem lies. "the over-riding urge to get the autopilot engaged asap".

Why is this so. If the thunderstorm is that close then commonsense would surely dictate you simply delay the take off until the flight path is clear. And even if circumstances dictate you depart into a thunderstorm then it takes only a few seconds to engage the autopilot into heading select. The radar should have already been on and tilt control organised before the take off roll.

In any case, there is a third way out, and that is have the first officer fly the departure under your direction while you study the flight path around a storm on the radar. When time permits and at your direction as captain, he can engage the autopilot. It seems from the various accident reports mentioned that it was the undue rush to engage the aautopilot that caused distraction to the primary task of flying the aircraft until such times it is appropriate to carefully engage the autopilot.

Of course if the first officer is incapable of hand flying in IMC because of his inexperience and lack of training as a pilot, then it becomes a single pilot operation - not healthy under thunderstorm conditions. I suspect the latter comment is often true in some airlines..

[odericko2000]

unfortunately i beg to differ with your last statement, word has it that investigations confirmed a break in the controls meaning the F/O was putting conflicting inputs to the captain and in the right direction for the recovery, unfortunately in this situation only the spoilers are controlled by the F/O and the ailerons by the captains stick so very little he could have done.

Classic scenario of CRM failure in the cockpit

[PLovett]

odericko2000, I am at a loss to understand what you mean by a break in the controls.

This did not appear in the final report and my understanding, imperfect as it is, is that in a Boeing there is no discontinuity in the controls, that is, both control columns have full authority.

However, there was far more failing in that cockpit than CRM.

[odericko2000]

@Plovett,
the ailerons on the 73ng are connected to the captains control wheel via the aileron feel centering unit whereas the F/o control wheel is connected to the spoilers via the spoiler mixer and the two controls are both connected via a cable drive system giving both control columns full authority over the ailerons and spoilers.

in the event that the ailerons are jammed the FOs control column will then break away n the column will move the spoilers only for roll control and vice versa.

in this case the captains column had an opposing force to the First officers having an effect equivalent to jammed ailerons, hence each of the control columns was controling different surfaces in this case the captains controling the ailerons n the FOs the spoilers.

But all said and done the recovery by the FO was initiated too late to have any impact n i concur there was lots more than CRM failure

[Lonewolf_50]

A question for those in the military...
Would a magnetic anomaly detector, i.e. one of those things you hunt subs with on Nimrods, P3s S3s etc detect a large metal mass, like a 2 tonne jet engine in the jungle ?

Not likely.

Tried to find an F-16 that crashed near Adana Turkey, 1985, using MAD on my helicopter.

No luck.

[flyawaybird]

Comment by Skylion:
<Kenya Airways originally intended to temprarily employ foreign contract pilots to assist the Kenyan Pilots through their period of rapid growth. This was rejected by KALPA>.

I read of the above air accident with interest because a lot of people in Kenya do not seem to know what actually happened. They attribute the accident to the bad weather as was originally foretold.

Just a comment; during the time of East African Airways, this was the case, where expatriate pilots trained the locals. I remember East African pilots flying for long periods as co-pilots both on domestic and international flights, before they qualified to pilots. I know there are a number of qualified and experienced Kenyan Pilots, formerly of East African Airways.

Just wondering why would Kenya Airways Management give in to KALPA in rejecting this arrangement:confused:, when actually it would conform with the safety regulation as stipulated by ICAO. Is Kenya Airways not a member of ICAO? And also why doesn't the KQ management put experienced pilots on this West African Route which has already claimed two Kenya Airways aicrafts and a number of fatalities?:confused::(

How sad this was!:sad:

[flyawaybird]

Commenting on Arkroyal: "Remembers Capt. was ex=military. You could be right. What I know is, he was employed by KQ as a flight steward initially, then after a couple of years KQ was recruiting some pilots and he applied and was accepted. What I don't know is whether KQ sponsored his training or not, since he was already working with them or where he was sent for training. That I don't know.:confused:

[flyawaybird]

Noelbaba's third paragraph; "The crash report compiled by the Cameroonian Civil Aviation Authority, found the captain did not adhere to the standard operating procedures and the plane took off without authorization from the Air Traffic Control".

At the time, there was a rumour circulating in Nairobi, that when the captain was refused permission to take off due to bad weather by the Cameroonian ATC, he called Nairobi to consult with Titus Naikuni,and that the captain :(was told to take off immediately and return to Nairobi. Whether this rumour was true or not, it is only Titus who can confirm.:oh:
This does not excuse the pilot's error.:sad:

[flyawaybird]

General questions to experienced pilots

Is Boeng 737-800 a safe aircraft, considering a number of accidents, this type of aircraft has been involved in, up to now? Or is it too difficulty to fly?

[kotakota]

1. Management gave in to KALPA when they threatened an all-out strike to prevent expats joining.
2. KALPA even managed to get IFALPA to issue a Notice advising pilots not to join KQ . This was without any 'normal' basis , ie KQ had not sacked anybody etc.
3. Cannot believe any Captain would take an order over the phone to take-off ever , especially in such dire conditions. This is one rumour too far.
4. I fly the 800 , it is a fine aircraft , but like any aircraft it does not like flying in Thunderstorm cells.

[barit1]

flyawaybird:

Considering the very large number of 737NG (-600/700/800/900) aircraft delivered to date, the number of accidents is not out of line. And I believe a little research will show that pilot lack of discipline and inexperience are frequent accident contributors.

The data are readily available online.

[Frangible]

Regarding the captain's alleged consultation with Nairobi before taking off, I know no more than what the rumour says, but it could explain one puzzle that I never saw any comment on. Permission to take off is not requested on the CVR transcript.

[B777Heavy]

Commenting on Arkroyal: "Remembers Capt. was ex=military. You could be right. What I know is, he was employed by KQ as a flight steward initially, then after a couple of years KQ was recruiting some pilots and he applied and was accepted. What I don't know is whether KQ sponsored his training or not, since he was already working with them or where he was sent for training. That I don't know.

Paid for his own training in the US.

1. Management gave in to KALPA when they threatened an all-out strike to prevent expats joining.
2. KALPA even managed to get IFALPA to issue a Notice advising pilots not to join KQ . This was without any 'normal' basis , ie KQ had not sacked anybody etc.
3. Cannot believe any Captain would take an order over the phone to take-off ever , especially in such dire conditions. This is one rumour too far.
4. I fly the 800 , it is a fine aircraft , but like any aircraft it does not like flying in Thunderstorm cells.

1.Not true, get your facts right...since when do managements listen to unions to this extent? I know a few KALPA members and this isnt the case. What does the case of having foreigners fly in the airline have to do with the crash? Are you saying local pilots are "inferior"? I have flown in places with several diverse nationalities, some are good, some crap. It has nothing to do with nationalities or backgrounds!
2.I dont know whether this is true either! From my sources, its not true
3.Nope, according to some people I had talked to, it was more of a case of "get- thereitis"

[kotakota]

777 Heavy , I stand by my statement , check your own facts please. As you say ' I do not know if this is true ' is no argument . I actually saw the Ifalpa Recruitment Ban notice for KQ .
As for Point 1 , I stand by that too . And please don't play the race card with me . I fail to see how I said anybody was inferior . The fact was that KQ needed experienced crew to help get the training/upgrade demand moving . If there were sufficient experienced Kenyans available to do this in the first place , then there would have NEVER been any talk of recruitment would there ?
Of course there are KALPA members with moderate views , all unions have them , but they are unlikely to be the leaders. Besides , I learnt a lot about the stance from a 767 Captain in the Aero Club at Wilson . He was charming and polite , but made it very clear where they stood. Fair enough I thought , won't waste my time pursuing that paper trail !
If you can prove me wrong on any of my points , please go ahead , but please check your 'facts' first .

[flyawaybird]

777 Heavy,

First of all, some of my comments were based on rumours by the Kenya newspapers and KQ staff speculation. We get informed by what we read from the media, respective company staff or from threads here. Rumours cannot be facts, although it is often said, that there is always a grain of truth in rumours. We deal with a lot of it here at PPRuNe. I must say I really like reading what pilots write here, because some things you don't get to hear elsewhere.:D

This is not personal, but was merely replying to Skylion's comment about the training and experience of KQ pilots. If you go back to my comment you will see that I seem to know that there are very well trained and experienced KQ pilots ex-EAA. an airliner i worked for, sometimes back. Any pilot of whatever race with good training and good experience can master flying very well. There is a saying that goes "Experience is the best teacher". This is very true but good training is also required. I believe this is very sensitive where pilots are concerned considering where they are operating from and involving many passengers entrusted in their capable hands and sober minds.

I don't remember talking of KQ sacking anyone.

About of the captain of the ill-fated A/C being called back by KQ CEO, this was speculation from the KQ staff, otherwise it won't be easy to know such internal details.

[Brat]

Sadly would seem to be another chain leading up to the event.

Substandard Captain, according to his airline records, making a bad decision to depart. Extremely bad weather. Poor CRM with a very junior and inexperienced FO intimidated shortly before TO by the Captain. Mistakes in operational procedures. lack of piloting skills to correct the situation that then developed as a result. Neither possibly should have been in the seats they occupied

In fairness to the Capt under the prevailing circumstances he may well have been tense and worried. Who would not be with the prevailing weather conditions where apparently even the ATC were debating whether to allow him to depart. He already knowing that past performance had meant him being under airline scrutiny probably reluctant to disrupt the schedule.

Insufficient emphasis placed on basic handling skills in todays airline training environment. Although not a factor here the present situation where training organizations place new FO's with companies to 'gain time on type' leaving the Companies Captains to act as trainers is also a situation that seems unhealthy, automatics in after lift-off until time to land with little or no handling to avoid any chance of infringements. Would also seem to be loading the odds against the Captain should things go wrong with low time inexperienced FO's.

Under the circumstances here it is unlikely that the Capt based upon his purported history possessed much in the way of basic handling skills. The FO was unlikely to have had the time to learn much basic handling let alone in the type he was in. In the report though it does seem that he 'may' have had a better idea of what was going on and did attempt to give the Captain some feedback, as well as probably fighting for his life and attempting to do something rather than just sit there and go in.

Based on the reported situation the FO may well have been already flustered by his Captains attitude and previous behavior, and worried about extreme weather, leading to his not checking/initiating autopilot actuation.

Inability of either crew-member to see early enough that an unusual attitude was developing, or to correct the situation when it did, with both apparently applying opposing inputs when they did attempt to retrieve the situation. This has happened to more experienced crews in better conditions, Air India 747 rolling inverted at night, and some similar elements to the loss of control on the Gulf Air Airbus accident on the night overshoot at Baharain with a possibly substandard Capt and inexperienced FO.

Politics does sometimes play a role and may have here. The captain despite poor performance continued operating in command, the FO possibly without the experience/time to be where he was, the airline reluctant to fill gaps with expats. First route training Capt of mine in EAA was a Tanzanian and the best Dak training Capt I had the privilege of flying with. As someone has pointed out there are simply good pilots and bad pilots with everything in between.

This one sounds as though it may have been the wrong people in the wrong place at the wrong time for the wrong reasons.

[flyawaybird]

Your comment is well put and I would only wonder why KQ management, knowing the capt's performance and considering the very young FO at 23, capped with the frequent West Africa bad weather, did not put a better pilot in command or an experienced FO. This is very sad of the victims' relatives. :O to KQ.

[Mshamba]

"did not put a better pilot in command"

Eh? Did anyone know in advance about that?

Or are there any lists with levels of "goodness" somewhere?

What i dont understand is the experience of the FO. Was he still under supervision, or not? And how is the supervision organizied with safety pilot? For those hours (i remember 50...?) in the airline i am working for, a FO would be under supervision with a special training captain AND a second officer as a safety pilot.

[flyawaybird]

Mshamba "did not put a better pilot"

No one knows in advance of any happening. But don't think KQ flight operations should be concerned who is flying where. The roster is often made way far in advance. It is up to the management to make sure pilots are trained well, experience and if need be, be given refresher courses. There is no execuse for ignorance or overlooking certain vital standards which should be enhanced.

[Mshamba]

What you probably mean is the legitimation for several airports, which are difficult to fly in, like Funchal/Madeira for example. But Douala certainly isn't, so special experience is required "only" due to the harsh weather out there on the west coast. And that, i assume, all pilots (captains) at KQ should have! Maybe i'm a bit too credulous?

Maybe you think about KQ differs between captains for "westbound routings" and "the rest", but i doubt they do, and i also doubt it would be necessary, as red/magenta on the WX tells everybody the same: don't fly into, end of it. So simple.