Air France rejected T/O in Lagos

[gb777]

Does anyone have more details about this reject T/O in Lagos on Jan 13?
Must be a high speed reject to blow some tires.

http://ndn.nigeriadailynews.com/templates/?z=8&a=22348

Air France re-route passengers stranded in Lagos
Wednesday, January 13, 2010 - Wole Shadare


ONE of Europe's mega carriers, Air France had its passengers stranded at the Murtala Muhammed Airport, Lagos, following technical problems which damaged the tyres of its aircraft. The pilot was said to have consequently aborted take-off.

Following the problem, the airline accommodated all the passengers in Eko Hotels, including 48 passengers from Port-Harcourt, Rivers State.

One of Air France's officials, Mr. Toyin Alaran, in a statement made available to journalists yesterday said, "There was a "Technical no go" on the Lagos Murtarla Muhammed Airport runway when Air France flight AF855 was taking off on January 11.

"No risk taken, pilots decided to interrupt the taking off. With such a strong breaking, few tyres were damaged and need now to be replaced by new ones about to arrive from Paris this afternoon with some technicians. All passengers were accommodated in Eko Hotel, including 48 passengers from Port Harcourt."

Alaran disclosed that all the passengers had been re-routed on Air France and KLM flights tonight (yesterday) and on some other airlines flights from Port Harcourt and Lagos.

The carrier had recently re-organised its operations to Nigeria with flights streamlined as Paris-Lagos-Port-Harcourt, using Boeing 777-300 aircraft.

In its maidem operations on the new route, the airline said it would now combine the Paris-Lagos flight, with the direct Paris-Port Harcourt flight previously operated with an Airbus 319 aircraft.

According to the airline, the new wide-body aircraft is configured with eight First Class seats; 67 Business Class seats; and 250 Economy Class seats.

This, it said, would help the airline to meet additional capacity, particularly in cargo demand.

"The flights will operate via Lagos, while departures from Paris de Gaulle will be at Terminal 2E.

"The wide-body Boeing 777-300 on the Port Harcourt route offers improved services such as a tri-class cabin with First, Business and Economy classes, improved baggage allowance (two pieces of luggage weighing less than 23kgs each in Economy class, instead of previous 20 kgs allowance), personal in-flight entertainment in all cabins and all products and services of Air France's international long haul standards," the statement read in part

[silverware]

Monkey on the runway?

[jeff64]

There is a huuuuuge topic on french forum radiocockpit (RadioCoco • Page d?index (http://www.rcoco.com))

Lagos was a short stop to board some pax. The crew failed to arm AT before departure.
On takeoff, pushing TOGA didn't engage AT (for cause, it wasn't armed).
Instead of applying procedure (manually set thrust and think about it later), the captain tried to arm AT. But instead, engaged Auto Pilot.
On VR, captain felt the controls were heavy, thought on a stabilizer jam, and decided to reject.

According to Boeing Statement, there is 7 another cases of AP unattentioned engagement during takeoff roll.
It seems a soft update is in development to prevent engaging AP on ground.

[gb777]

Thanks Jeff
Much appreciated

[Locked door]

Holy Crap.

If that's true Air France have totally failed in improving the safety ethos of their pilots post the Delta audit.

Was it a coincident V1 / VR? If it wasn't it's a bloomin' miracle they didn't write off another a/c and hurt more people.

LD

[jeff64]

Like someone said on rcoco, hopefully, it was not raining...

[jeff64]

This is an air france bulleting destinated to the air france 777 crew, posted on Rcoco forum.

this is my traduction, so sorry for the mistakes.

On takeoff from lagos, during the night between 11th and 12th of january, the F-QSQI [ndlr : it must be the F-GSQI] crew initiated a high speed RTO, and the airplane came 900m from the runway 36L threshold.
On VR, the captain who was Pilot Flying felt a heavy strength on the controls, and thought about the stabilizer jam. He estimated the aircraft was unsafe to fly.
He aborted the takeoff, maximum speed reached was 161 kt, and deceleration was -0,48g.
After self taxiing back to the stand escorted by security, 6 tires deflated, brakes were cooled down by firefighters. An information communicated to crew and passengers enabled a disembarkation by door 1R.
The crew, once at base, was welcomed by the division.
All the brakes and tires have been changed, a fuse and boogies inspection is in progress.
The ASR reveal the following facts :
After pushing the TOGA buttons, the engine EPR didn’t increase.
The captain manually set the takeoff power and observe the A/T is not engaged. Deciding to arm it, he engages too by inadvertance the autopilot. None of the both pilots notice it during the takeoff roll.
Boeing recorded 7 AP ground engagement cases on B777 on similar conditions.
What are our protections ?
If the setting thrust sequence is not conform ather the N1 stabilisation at 55 % and the TOGA push, we have two options :
- rejecting takeoff
- continuing takeoff with AT unavailable, the thrust needing to be set manually by slowly pushing the throttles to takeoff thrust. Thrust adjustments by N1 indications must be done before 100 kts. In this case, THR REF does not appears on FMA.
Also, a slight forward pressure on the yoke increase the nosewheel efficiency for lateral control until 80 kts.
During crosswind, wings must be maintained horizontal by using the ailerons control (yoke in the wind) as necessarly.
Those two actions on yoke allow to identify a possibly control jam during takeoff roll.
Bla bla bla bla

[Piltdown Man]

I thought V1 at Lagos was at -2kts, ie. on Push-back.

PM

[hetfield]

High energy RTO with 161kts followed by taxiing back.....:=

[411A]

None of the both pilots notice it during the takeoff roll.

Typical, for a two man (person) crew.
Ahhh, it is nice to have that one fellow that can set the thrust for you, and provide that third set of eyes to catch possible mistakes...the Professional Flight Engineer.
Lucky us...we have one:ok:

[Saint-Ex]

Used to have T shirt en-scribed "Happiness is V1 at Lagos"

[captplaystation]

With the greatest of respect I don't think moving it to a "spotty spotters" (well not quite, but slightly in that direction) forum is taking it seriously.

The serious issue here, is that Air Chance, on a different Runway/Day, would have had another hull loss here, caused primarily by poor MCC. Maybe "just" an RTO, but @161kts, many places where this could have ended VERY badly.

For this reason I am slightly mystified why this thread wasn't left where it would be seen my the maximum number of pilots, just in case Boeing hasn't been too keen to publicise this fairly common (well 7 times is 7 too many ) occurence.
From a purely air safety point of view I rest my case, & well, a bit of Frog bashing never goes amiss ;) Hell, they are even bashing themselves now. :oh:

Regards

[cheesycol]

Close the loop. If you don't, one day, something will bite you.

[CONF iture]

Thanks for bringing back the thread !
High energy RTO with 161kts followed by taxiing back..... :=
Interesting comment.
Curiously, the FCTM does not say much on what to do or not to do following RTO.
Would you comment further ?

[captplaystation]

I guess he was thinking (correctly as it seems to have transpired ? ) of fusible plugs.

V1 VR V1 (again) doesn't usually end this well.

Give thanks to long Nigerian runways & Boeing 777 brakes :D

[hetfield]

Would you comment further ?RTO in the high energy region (> 100kt) may seriously affect brakes, tyres (as it did in this incident), hydraulic lines and wires. Chances of a wheel fire are very high.

Remaining on the runway and asking for firebrigade and tech support gives you

- more space for the firebrigade than on a taxiway
- info about the tech status of the aircraft
- enough room for the slides if you need to evacuate

High energy RTOs are serious incidents and there is absolutely no reason to continue normal ops.

Cheers

[SIUYA]

hetfield....

Would you comment further ?

Yes, I would. Referring to a little 'event' that I've heard occurred in Dhaka Bangladesh in the late 90's.

RTO in the high energy region (> 100kt) may seriously affect brakes, tyres (as it did in this incident), hydraulic lines and wires.

Yep...........agree. The Dhaka RTO was reported to have been initiated >VR. :eek:

Chances of a wheel fire are very high.

Indeed they are, and I'm told that 7 of the 8 MLG tyres AND wheel rims were destroyed by the subsequent fire at Dhaka.

Remaining on the runway and asking for firebrigade...

Aircraft at Dhaka apparently remained on the runway because of all the damage to the MLG, so it couldn't taxi any further! :rolleyes:

There was reportedly no request from the crew for the aerodrome RFFS to attend. :ugh: Fortunately for everyone on board the A300 at Dhaka, the RFFS apparently DID attend, and very promptly.

By the way, it's an ACCIDENT when the damage is not limited to the engine or its cowlings or accessories, propellers, wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in the aircraft skin. (Reference: ICAO Annex 13).

[lear60fellow]

411A, I wanna fly with you guys, I love those buddies behind us

[M.Mouse]

Curiously, the FCTM does not say much on what to do or not to do following RTO.

In my company we have quite comprehensive guidance. After stopping and carrying out the immediate actions, if an evacuation is not required then the next step is calculate the brake energy figures from the QRH to establish how safe it is to move or not as the case may be. The B777 is pretty amazing in this regard.

Some years ago I had an RTO at around 160kts at close to max TOW. We were able to safely taxy off the runway and back to the apron with brakes that did not reach the range where fuse plugs were in danger of melting, albeit they were hot!

[sitigeltfel]

Boeing 777 RTO at MAUW during certification

wXpjBxD0Rhg

[Bernoulli]

Previous poster just beat me to it! Here's a link to the RTO tests on the A340. It's got to be pretty serious to consider a stop at high speeds. The AF chap would have been convinced his aeroplane wasn't going to fly so did what he thought best in the couple of seconds available to him. As for taxying far afterwards..... well.....:ooh:

YouTube - Airbus A340-600 Rejected Take-Off test (subtitles) (http://www.youtube.com/watch?v=hRzWp67PIMw&feature=PlayList&p=2E88C856D0D70C67&playnext=1&playnext_from=PL&index=14)

(sorry, don't know how to do that embedded video thing)

Bernoulli

[hetfield]

Oh my God:O

Please oh Lord, let it be a fake.....

[sitigeltfel]

(sorry, don't know how to do that embedded video thing)



Bernoulli.............check your PMs.

[Locked door]

'Tis not a fake. The problem with the a340 test was the fusible plugs failing to melt at the correct temperature, leading to tyre overpressure explosions that put flammible material in contact with the brakes. In the 777 test you see the tyres deflate before the five minutes is up, but this is perfectly allowable. The a340 test was repeated with different plugs and all was well.

It's worth bearing in mind that your fusible plugs may perform just as badly when you reject, whatever type you're in. Always a good idea to get the fire services to your location pronto, even if all seems well initially!

LD

[atakacs]

In its maidem operations on the new route, the airline said it would now combine the Paris-Lagos flight, with the direct Paris-Port Harcourt flight previously operated with an Airbus 319 aircraft.

Sounds like a pretty long route for a 319...

[beaver34]

it's an A319 with additional center tanks

[CONF iture]

Thanks for your comments.

On the Airbus side, information is minimal :
If tire damage is suspected after RTO, inspection of the tires is required before taxi. (some restrictions apply depending the number of damaged tires)
IMO Airbus should provide something more substantial on the subject. A chapter in the Abnormal Operation of the FCTM would be the right place.

Other questions :

What kind of equipment use the firefighters to cool down the brakes ? Are they simple fan blowers ? What is the procedure for the firefighters after a RTO ?
Also, I’ve been told that some RTO can even require a landing gear replacement depending on the level of heat accumulated in the landing gear body … Any comment ?

[DA-10mm]

Saint-Ex:

...or leaving their FIR...

[hetfield]

What kind of equipment use the firefighters to cool down the brakes ? Are they simple fan blowers ? What is the procedure for the firefighters after a RTO ?
Also, I’ve been told that some RTO can even require a landing gear replacement depending on the level of heat accumulated in the landing gear body … Any comment ?

a) AFAIK they use water/foam. Fan blowers would increase the risk of a brake fire.
b) Yes, if the boogies get too much heat they must be replaced

Cheers

[wings folded]

b) Yes, if the boogies get too much heat they must be replaced


The only way my boogies get too much heat is when I stick a lit match up my nostril.

I rarely do it nowadays because it is not very comfortable.

[Huck]

Close the loop. If you don't, one day, something will bite you.

I prefer:

"Live another day. Check your FMA...."

[moonburn]

What kind of equipment use the firefighters to cool down the brakes ? Are they simple fan blowers ? What is the procedure for the firefighters after a RTO ?

Air conditioning carts are ideal, however I have used air start carts many times and although the airflow is warm it is still very effective in reducing brake temperatures to safe levels, you will usually have to 'do it yourself' as most ground staff will not go anywhere near smoking wheels. If fire is already apparent the only really safe option is dry powder extinguishers,although Co2 can be bounced off the tarmac and onto the fire. Co2 or water directed straight onto the gear will nearly always cause catastrophic thermal shock and explosions containing shrapnell as well as rubber. Oh yeh, and ONLY approach from fwd or aft or you could recieve a facefull of wheel !
Safe flying.

[Nil defects]

Quote: "Lagos was a short stop to board some pax. The crew failed to arm AT before departure. On takeoff, pushing TOGA didn't engage AT (because, it wasn't armed)."

So why were the autothrottle arm switches off? There is no reason to turn them off and particularly as the aircraft was on a transit stop anyway.

But even on a normal turnaround or long nightstop there is no reason to turn the auto throttle arm switches off. There is no Boeing procedure that calls for them to ever be selected off on the 777 (except in a non normal or engine failure type event)

:ugh:

[Dont Hang Up]

If jeff64's figures of 161kt and 0.48g deceleration are reliable (and assuming 300 000 ToW) then at the onset of deceleration the braking force would be generating 117 Megawatts.

The aircraft would have stopped in just under 18 seconds covering around 730 metres (lucky to have that much left at Vr).

The total heat generated would be around one billion joules - sufficient to heat two and a half tonnes of cold water to boiling point.

Tea anyone?

[jeff64]

Nil defects : I don't know why. Don't know the AF 777 procedures, but on the 744, the after landing flow (air france procedure) requires the AT switch to be turned OFF. Maybe it is the same on the 777.

Dont Hang Up : The figures come directly from a note written by the AF 777 chief pilot to the AF 777 drivers. The original image is below (in french)
http://img215.imageshack.us/img215/3712/stop777001.jpg
http://img687.imageshack.us/img687/9377/stop777002.jpg

[captplaystation]

Well, at least it will give the Air France "Safety Panel", that flightglobal.com say is starting its interviews next week, something topical to discuss, rather than same old same old :D

[IFR OnTop]

Being not a 777 jock I do fly the 73 NG's. So as it's of the same family I guess there are some similarities.
1) The " Before t/o check list" does it specify "Autothrottle....Arm"
2) what is the PF doing pressing buttons on the takeoff roll when his head should be "outside"?
3) What is the PM doing, Im sure, "outside" when he is suppose to be monitoring PFD's, ND's, Eng Inst, etc?
Anyway mine is not to criticise the pilots but it seems that when there is a slight deviation from the norm human instict takes over and survival mode kicks in.
If CRM/SOP's was followed it would be a simple case of back to basics and doing a bit of manual flying.
We learn everyday.

[despegue]

maybe your checklist on the B737 says "A/T Arm" but mine certainly doesn't and it is sometimes forgotten. Not a big deal, you don't NEED an A/T anyway...

[fdr]

The B777 Auto throttle, ATR is not like the B737, B744 or B757/767 system.

It is a true full time system, and there is only NNCL procedures to disarm the ATR, unless a Flight operations department has decided to apply their corporate wisdom to change the manufacturer's procedure. This can occur from either a operator perceived deficiency in the manufacturers procedures, to standardise with other types in the operators fleet, etc... Where the procedure deviation may vary from the AFM, then a No Technical Objection is required from the manufacturer.

There is no normal condition where the ATR is better served by being turned off, including single engine operations (although if you have no TAC, no PFC's and degraded hydraulics and single engine, it is easier to fly manually without the ATR.... ). On a manual landing at 25'RA the ATR retards the thrust to idle, unless the aircraft mode is FLCH or TOGA.... The pilot is not restricted in overriding the ATR manually at any time, and once the override pressure is released, the throttles revert to the commanded thrust level. it is infrequent that this occurs, even in modest windshears, IMHO (~8,000 PIC on type).

ref: FCOM 4.20.8, FCTM,

This is in stark contrast to the B737/747/744/757/767 system design and performance.

AF did have a mishap related to manual flight with an inadvertent ATR re engagement on a B744 landing at Tahiti, which ended in tears and photo opportunities, which would certainly tend to make people cautious about the ATR arming switches of a B744, but the B777 is not in so many ways (good and bad...) a B744.

This event should be a wake up call for AF, it is an opportunity to learn from an accident without having suffered same, as this very nearly was a catastrophic event. maturity of their flight operations department will be evident in their response, either shooting the messenger, or working out why their system of training, procedures, and practices failed miserably on the day, and by the benevolent smile of lady luck avoided a major mishap, from a minor procedural oversight.

The decision to continue a takeoff in manual thrust when the ATR does not engage in TOGA mode is one that I have misgivings on, as it indicates a technical or operational defect exists in a time critical phase of flight. The FCTM procedure does not call or suggest fault finding, just manually applying the requisite thrust level. fault finding and mode changing on the fly is a potentially hazardous proposition, as either an error of analysis, switching or other can occur and little or no crosschecking will be conducted. This is anathema to 2 pilot operation SOP's. The subsequent defect identified by the pilot of a flight control restriction at the point of initiating the rotate, is apparently not cognitively linked to the non standard procedure of engaging the ATR (accidentally engaging the AP). The mode changes are not identified by the crew apparently on the roll during this event at all, indicating some limitations of monitoring of crews in a high workload environment. This is not a criticism of the crew per se, it is an observation of the limitations of the human to cognitively multi channel in a dynamic environment. The oversight of the ATR switch in the preflight check, where it is listed in the POM, Ch5.3 needs also to be assessed in the light of duty time/fatigue/etc before lining up the messenger against a suitably pockmarked wall.

This event should serve as a warning to any organisation that is complacent in their operational safety record, procedures and CRM principles, to the point of hubris.

[Flight Detent]

just my 2 cents worth....

I am 100% behind the comments of "411A" here, why oh why have we gone this way, it's proving inept time and time again! (even the original idea for the change has been proven rubbish!).

Yeah...I know...all the pilots will come back in a gigantic wave telling me they don't need a professional Flight Engineer, he's not needed, we can do it all ourselves.

BUT...it's being demonstrated time and time again that 'when everything's fine, everything's fine", but when you REALLY need instant technical expertise/another set of eyes, right there in the flight deck, the PFE is being missed sorely!

This is simply another example of that, one that seriously could have ended very, very badly!

I normally say "Cheers" at this point, but I don't think it's appropriate in this environment!

FD:yuk:

[stilton]

I realise this AF incident was a different kettle of fish but, FDR, I don't really think we've got to the point where we have to reject a take off just because the autothrottles dont engage.



During take off a few years ago on a 767-400 our AT'S did not engage (AT was armed) so we manually set the thrust and carried on, no big fuss.



This sort of coordination was done for many, many years on more 'primitive' Aircraft. Granted it's easier with an FE and i'd be happy to have them around still as well, even so..



In our case we never regained use of the AT'S (faulty thrust computer) so we set our own power from LAX-HNL, a non event.




Having flown several 'Jurassic Jets' for many years I always considered Autothrottles to be a (very nice) luxury.



Unless there were other failures I would make the same decision today.

[Airbubba]

During take off a few years ago on a 767-400 our AT'S did not engage (AT was armed) so we manually set the thrust and carried on, no big fuss.

One clue that the flaps on a modern Boeing are not at a takeoff setting is that the autothrottles will not engage. I'd sure take a good look for something out of place before continuing. Of course, you should get a config warning if you continue to push up the throttles (or thrust levers or whatever they are called these days). And, nowadays, the feds seem to want you to taxi back to the end of the line, get a deferral number from maintenance and refer to the MEL if you go with any system inop even if you know a reset will cure the problem (e.g. yaw damper inop). Some of this seems to depend on the POI and the times.

Also, with the thrust management computer inop, nuisance exceedance reports will be put on the QAR tape, I speak from experience.:) Engine indications will turn amber if you exceed max continuous on takeoff even though it is not a limitation in the first five minutes of the flight.

[PantLoad]

My opinion, for what it's worth, is that I agree wholeheartedly with 411A. Having been a flight engineer, myself, I was able to sit back and look, from a distance...if you will....and see the forest for the trees. A respectful callout to the guys up front would bring to their attention something that wasn't quite right.

A similar situation exists in the simulator. The sim instructor gets to see (and take in) a lot more of what is going on....because he (she) is sitting back and observing the whole picture.

A good flight engineer is worth his weight in gold. (The same can be said for a good first officer, by the way.)

Today's planes are designed with automation that eliminates the need for the flight engineer. But, I'd much rather have a good flight engineer, instead of all this automation.

My opinion only....


Fly safe,


PantLoad

[stilton]

Points worth considering AB but no other malfunctions / abnormalities were present.


The flaps were down already and had been checked !



It was a very simple issue to address manually, no exceedances were made on any engine limits as we carefully monitored the power (just like we used to do on older Aircraft)


Doubtless a QAR record was kept, thats good. After writing up the incident in detail in the maintenance log and with our flight operations department our actions were never questioned by anyone in Flt Ops management, maintenance or the FAA.


Not sure if you realise the Aircraft can be dispatched with autothrottles inop.
Everything else works very well thank you.



I am curious to know what else you would reject for.

:rolleyes:

[wfajobi]

I was a passenger on this flight,this would explain why it took so long for the thrust to kick in,until deep in the runway say 1500ft.

Will be a good topic for CRM today!!!

The stop over in lagos was scheduled about two hours.

[Airbubba]

Not sure if you realise the Aircraft can be dispatched with autothrottles inop.

Gee, I didn't know that! Really? Wow...

Anyway, the feds are big on deferrals, paperwork and decision matrices these days from what I can see.

I am curious to know what else you would reject for.

Prior to 80 knots, which is when you would discover that the autothrottles would not engage, we are trained to reject for system failures (along with a laundry list of other things like unusual vibration, master caution and the usual engine fire or failure). It may be different where you work, like I said, some of this depends on the POI and the latest thinking.

[fdr]

I realise this AF incident was a different kettle of fish but, FDR, I don't really think we've got to the point where we have to reject a take off just because the autothrottles dont engage.

Until 12 months ago, an open flight deck window was not cause for a low speed RTO (<80KIAS), now it is. The conditions that determine a RTO at low speed is well stated in the Boeing QRH NNCL.

Off hand I can think of 4 events where the ATR didn't engage, and a flapless takeoff ensued, which resulted in fatalities: DC-9, MD80, B737 x 2. I know of numerous cases where the ATR didn't engage on B744's, and after messing about finally the crew manually set thrust, to find the next warning was CONFIGURATION-FLAPS. In 2 cases the crews set the flaps on the roll.... neat trick- low drag takeoffs.....

Setting the thrust back to idle and pondering what is going on, and ensuring that the procedures and checklists have been followed, seems a fairly low rent/low stress solution, as the thrust is normally set from stable (various engines various values) around 10-20Kts GS... this is a fairly low energy state.

The FCTM does allow manual thrust setting, no question, however the crew fault finding and changing switches without adhering to standard crew actions and callouts as characterised in the Introduction to the Boeing QRH is going to be hard to justify in the light of an erroneous selection being made on the fly, or following an ad-hoc procedure.

Systems wise, program safety is not predicated on the best pilots and operators, it is based on the lowest levels of each on a bad day.

[SIUYA]

fdr....

The oversight of the ATR switch in the preflight check, where it is listed in the POM, Ch5.3 needs also to be assessed in the light of duty time/fatigue/etc before lining up the messenger against a suitably pockmarked wall.

Excellent call! :D

[Airbubba]

The FCTM does allow manual thrust setting, no question, however the crew fault finding and changing switches without adhering to standard crew actions and callouts as characterised in the Introduction to the Boeing QRH is going to be hard to justify in the light of an erroneous selection being made on the fly, or following an ad-hoc procedure.

Yep, like I said...:ok:

[Tee Emm]

What is the PM doing, Im sure, "outside" when he is suppose to be monitoring PFD's, ND's, Eng Inst, etc?

Maybe looking for guided missiles, crap on the runway, kangaroos, stray lions or starving locals looking for road kill:ok:

[IFR OnTop]

Maybe looking for guided missiles, crap on the runway, kangaroos, stray lions or starving locals looking for road kill

Tee Mem
Sorry matey, no Roos here. The only wild animals here are corrupt politicians. Sorry I digress :eek:

[LEXAN]

Quote
"So why were the autothrottle arm switches off? There is no reason to turn them off and particularly as the aircraft was on a transit stop anyway."

To my knowledge, A/T are set off during taxi out because AF decided that if you mistakenly press the switch on the trust lever, you will get the take off thrust on the taxiway which was considered more dangerous than forgetting the A/T. It seems that they are wrong but SOP may have changed and I haven’ been flying this aircraft since 2003

[yambat]

I am with you guys who go the FE route, I still fly with the voice activated, hairy hand actuated throttle set up, will miss it when we finally move to something clever.
I do not fly these modern aircraft, but am still pretty alarmed that this situation occured, some lucky people there by all accounts.

[M.Mouse]

I am with you guys who go the FE route, I still fly with the voice activated, hairy hand actuated throttle set up, will miss it when we finally move to something clever.
I do not fly these modern aircraft, but am still pretty alarmed that this situation occured, some lucky people there by all accounts.

No one doubts the skill and usefulness of a Flighte Engineer but there is no job for a flight engineer on a modern two crew aircraft. I remember positioning from Melbourne to Perth in 1990 on an Australian Airlines B767. Out of courtesy I went on to the flight deck to say hello. I was amazed to find a flight engineer sitting in front of a small panel where some of the overhead panel had been relocated. He also had a secondary EICAS screen. He appeared bored out of his mind and, frankly, was superfluous to requirements.

What we have in this incident, if our understanding is correct, is poor adherence to checklists, poor SOPs and poor airmanship leading to a very serious error. Employing a flight engineer to cover for a pilot's apparent lack of training or airmanship would seem OTT.

[stilton]

Connecting the lack of autothrottle engagement to lack of flap extension is reasonable.



Just as reasonable as manually setting thrust after checking all else is well.

[Me Myself]

Not Australian airlines, this would have been Ansett.

To my knowledge, A/T are set off during taxi out because AF decided that if you mistakenly press the switch on the trust lever, you will get the take off thrust on the taxiway which was considered more dangerous than forgetting the A/T. It seems that they are wrong but SOP may have changed and I haven’ been flying this aircraft since 2003

This dates back to the 744 early days many many moons ago. It happened to the then Ops chief who, by mistake, activated the palm switch on a taxiway. It was a close one.
It was decided the switch was to be off before take off and to be switched on when approaching the runway.
Today, it is to be switched on before start up and switched off after landing.
On a 2 legs trip.................that's where the hole in the cheese is.

[M.Mouse]

Not Australian airlines, this would have been Ansett.

If Ansett flew white B767s with Australian in blue letters written on the side you are quite correct.

[DJ77]

On a 2 legs trip.................that's where the hole in the cheese is.
Why ? Are they keeping the engines running during the stop-over ?

[Flight Detent]

Hi 'M.Mouse' and 'Me Myself',

I was flying with Australian Airlines back in those days, and believe me, Australian did not have ANY B767s at all,

further, Ansett were the ONLY B767s in the world that had the FE mod (an ex-RAAF friend of mine used to fly 'em).

Ya shoulda been in a '72, they were the greatest, and that's the way I'll always remember it!

(Both airlines had them!)

The mob I'm in now (B737NGs), recently changed their procedures to get the A/T armed only when approaching the departure runway, simply for safety reasons, due the likelyhood of accidental TOGA actuation!

Digression complete!

Cheers...FD

[M.Mouse]

I have to eat humble pie and stand corrected then. Thanks for the information (both of you).

[yambat]

M.Mouse

Absolutely right regarding the superfluity of the FE in the modern flight deck. I have the fortune/misfortune to fly a Jurassic jet and have flown with our FE for 4 years now. I really appreciate his technical knowledge. I very much agree that this incident is a result of poor airmanship and a lack of adherance to SOP's.
Cheers
yambat

[Flight Detent]

Gentlemen...

In my humble opinion, I think you'all are missing the point here, well, most of you anyway,

As I see it, the point is that the flight deck automation has gone way too far,
we need to 'back off' somewhat, AND reintroduce the PFE, that's my point AND that of many others here and elsewhere!

In other words get the operation of the airplane back into the hands of the flight crew, not just have them being passengers to the automation, or worse, not knowing what to do when (not 'if') the automation let's you down, either as the result of mishandling or malfunction.
What was that the Airbus company released in a document recently, (surprisingly, from them), something to the effect that pilots in general (well, airline pilots at least) are losing their handling skills by using the airplane automatics most all the time!

From my first days in the flight deck, I have adhered to a short saying, which has always faired me well...."If it's electronic, it's unreliable", and I'm still here to repeat it, some 14,000 hours later!

There, I've said it!

Now bring on the automatics lovers!!

Cheers...FD :ugh:

[M.Mouse]

Would you care to look at the accident statistics and compare, say, the year on year statistics for jet transport hull losses for the past 40 years.

The implication of what you, and some others, are saying is that aeroplanes are becoming unsafer due to over reliance on automation. Sure there have been losses caused by inappropriate or inadvertent improper use of the automatiion but that is down to poor training, procedures or incompetence, all of which is not the fault of the automation.

Having flown both which would you rather do:

Fly a non-precision approach by hand or using an autopilot in vertical speed and heading mode or

fly a non-precision approach fully automatically in LNAV and VNAV (B777 because that is all I have experience of in doing so)?

So many situations which demanded very high levels of skill and interpretation and, therefore, an increased consequent exposure to possible catastrophic mistakes have reduced due to automation.

I remember being route checked on the B747 on a jumbo out of LAX and during the debrief I was criticised, correctly, for hand flying the aircraft to 10,000' or so meaning I was hugely pre-occupied with that task and had increased the captain's workload dramatically in what is incredibly busy and demanding airspace, not to mention one less pair of eyes able to keep a lookout.

I realise the likes of 411A would be able to fly more accurately while hand flying a non-precision approach and at the same time lecturing his FO about the appalling standards he observes in all other airlines but, as a lesser mortal, I cannot accept the premise that aeroplanes which require a flight engineer are inherently safer.

Edited to add that I have just found this which is raw data and does not take into account the increase in hours flown year on year: Fatal Airliner Hull losses. (http://aviation-safety.net/statistics/period/stats.php?cat=A1)

[doyll]

Not enough data in those Fatal Airliner Hull losses.

Need total number of miles/year, hours/year, etc. in order to get any kind of meanful stats.

[halas]

Over 10,000 hours before l even saw an auto throttle, it took a while to accept it's capabilities on the type l am on now, the 777.

Monitoring is our job description under SOP's, and it's when all turns pear-shaped that manual reversion is required. But the issue is understanding what you are monitoring before manual reversion is needed.

The FMA would have told the whole story. No THR REF means no AT. Back to basics, set power manually, 50% engines stable, set take-off thrust.

Raising a hand to manipulate anything on the MCP during the take-off is not only not necessary, but dangerous. Don't do it.

Lagos is not my favorite destination, and l am glad no one got hurt.

halas

[Razoray]

As I see it, the point is that the flight deck automation has gone way too far,
we need to 'back off' somewhat, AND reintroduce the PFE, that's my point AND that of many others here and elsewhere! In my humble opinion I think you are both correct. Automation is a great thing and has made planes safer in an ever busier environment. Unfortunately the PFE was a casualty in this process, mostly to save money. I would think it would be great to have the PFE back in conjunction with the modern automation. I feel with these new giant planes, flying thousands of miles and with new security concerns it is the responsible thing to do. If this were the case the modern PFE would be more of a computer geek. And the Captain would have more time to manage the aircraft. Kinda of like Captain Kirk.....

And if this were to happen some of you old geezers could help as consultants and trainers. Maybe that's the idea all along :confused:

[Killroy]

Can anyone tell me how it's possible to engage the autopilot when you are trying to arm the autothrottle?
I fly B73NG and the autothrottle switch and autopilot button are on different sides of the mode control panel, I thought (perhaps mistakenly) that the MCP layout was more or less the same on Boeing aircraft.

Thx

[wiggy]

The MCP layout is not standard across Boeings - Does anyone have a graphic of the Air France MCP? Is it indeed a standard Boeing fit?

FWIW on "my" 777 there are two Autopilot switches, one on the left of the MCP, the other on the right. There is also a single Autothrottle button just below and to the right of the Left Autopilot button, that "above 400', with the autothrottle armed, activates the appropriate autothrottle mode....."

[stilton]

In any case, on the 777 do you not engage the Autothrottles on take off with the TOGA switches on the throttles ?


Unlike our practice on the 75/6 I don't see a reason why anyone would be reaching for the MCP during take off on the Aircraft in question.

[ray cosmic]

http://img94.imageshack.us/img94/4863/mcpc.jpg (http://img94.imageshack.us/i/mcpc.jpg/)

Courtesy Airliners.net, here the original image:
Photos: Boeing 777-228/ER Aircraft Pictures | Airliners.net (http://www.airliners.net/photo/Air-France/Boeing-777-228-ER/0372661/L/&sid=9965dbd06faddce0860b108a20eb8e74)

[beaver34]

ATR are set OFF during taxi out in AF SOP.
They should be switched ON during preflight check by the captain.
On preflight CPT has to check his O2, thrust levers idle and ATR ON, and FO has to do all the rest including walk around and CDU entries.
I'm quite sure AF management will conclude the high workload of the CPT during turn around is the cause of this incident....

[Shingles]

AF is certainly in choppy waters on the safety front at the moment. They seem to be doing a lot of the right things but too no avail - yet. Is this analysis getting at the truth?:
"The Air France pilots' union was furious with the company last year when they suggested that the pilots should pay more attention to in-house operational instructions. This incident is yet further indication that the airline might have a point."
From here (http://insidetraveller.co.uk/blog/?p=770).

[338C]

Jeff reports that the Captain failed to notice he engaged the A/P rather than the A/T.

In a publication of B757 systems the author quotes the phrase "you live and die by the ADI". He refers to using the ADI to ascertain what autoflight modes are actually engaged.
Some operators require verbal annunciations of all FMA changes.
The procedure compels the crew to focus on the annunciations.
In this instance would a similar SOP have alerted the crew of an incorrect mode selection?

Jeff's information eludes to the Captain being the PF and the person engaging the A/T while also steering the aircraft. In this instance would the cockpit workload be better distributed if the PNF set the manual thrust and performed any other required functions at the direction of the PF Captain?
Such a procedure has the secondary benefit of bringing the PNF F/O more effectively into the loop.

Manual setting of T/O thrust does not appear to be a procedure that is trained for or practiced in the simulator. As a result when it is required on the line the procedure is a "novel" event. Performance on the first sector is often well below par. Crews fail to achieve the required thrust by the required speed and loose their monitoring capacity as a result of the task fixation.
The crew coordination required for this procedure is significant.
Would crews benefit if simulator sequences had more emphasis on events that utilise manual modes?
It is possible that CRM and management skills may improve while responding to the more demanding situation.

[stilton]

A point is being missed here. If the Ca was flying it would be normal for him to engage the Autothrottles with the TOGA switches on the throttles and have the PM verify the thrust is set properly.


Just like on many other Boeing Aircraft. Of course he would be steering as well as is normal if it his leg.


Or was he reaching for the AT arm switches on the MCP ?

[Centaurus]

Manual setting of T/O thrust does not appear to be a procedure that is trained for or practiced in the simulator.

We need to get all this in perspective. Tiger Moths and Spitfires, Lancasters and Fortresseses and ye olde Boeing 737-200 all had manual "thrust." Surely the requirement to actually train airline pilots how to manually shove open the thrust levers on take off has got to the ridiculous stage. Perhaps the next thing is to have airline pilots undertake an hour in a real flying Cessna 150 with a jumior instructor as part of cyclic training, just to get them out of automation dependancy. Much cheaper than a set of Boeing 777 replacement tyres.

[jeff64]

Till two years ago, Southwest Airlines didn't have AT installed on those 737 (200 - 300 - 500 - 700)
And I am not sure there was more accident related to thrust at southwest (at least at southwest, an accident like Turkish at schiphol wouldn't have occurred) than any other airline.
And still today, they are not allowed by SOP's to use AutoThrust on takeoff and on descent.

I was reading (again) the report on the Air France 744 swim training on Tahiti (1996 I guess).
744 landing by night from LAX. VOR DME approach. Manual flying but AT ON, approach in LNAV VNAV.
Approaching MDA, AT set go around thrust. The PNF announced "THR REF" but none of the crew analyzed the situation and the announcement.
The PF felt the force of the thrust levers wanting to move forward, but he restrained them. The speed increased to VREF + 35 and they noticed it, but didn't do any action and continued the landing.
5 seconds before Touchdown, the PF raised his hand to take the reverses, but number one engine spooled up to GA thrust (and again, they didn't noticed it).
The PNF announced "four reverses" (but that was not true) and some seconds later announced "errr, number one is not in reverse".
At this moment (about 10sec after TD), they noticed the number one was in full forward thrust, the ground spoilers were still down, and the autobrake was deactivated. Too late. 90 degrees right, right into the lagoon.

And I'm sure we can find a more more more cases of unreading or misreading of FMA. (how many cases of AP disconnect unnoticed by the crew ? Only in France, I have read two or three reports, and none of them was air france. By memory, an 310, an Bae146, and an 330.)

[M2dude]

Let's get the BEA to conduct an investigation. I'm sure that they will say that Boeing confused things by putting the A/P and A/T at diagonally opposite sides of the MCP (far too close together you know); The ATC at LOS for not warning them of this; perhaps the crew became dis-orientated by not being in CDG. Either way, I'm sure a report would blame anyone and EVERYONE except for the airline concerned. AGAIN!!
:\

[jeff64]

I think you badly know the BEA

They have no scruple for blaming everyone else than Airbus and the Airline, and this include the pilots.

In every accident since late 80's (habsheim, saint odile, toronto, cayenne, tahiti, concorde, 447, etc) the pilots were charged by the BEA (because they could not charge airbus nor Air France).

So in this case, even if we are facing a boeing and not an airbus, I think the pilots will be charged (but not air france who have changed the boeing procedure by inducing some unneccessary AT movements).

[HotelT]

Just wondering .. I don't know the minimum AP engage altitude (RA) on a 777, but normally it would be something like 250 feet after takeoff. What is the philisophy behind being able to engage an AP during takeoff in the B777 design? Why isn't this feature inhibited until the minimum engage height?

And yes, IMHO the AP switch might easily be confused with the AT switch in this B777 setup (and no, I don't need the old levers back nor the FE). Not to "blame" Boeing, but perhaps to learn in the process (especially if all that is broken is an ego and some tires/brakes).

Luck was on their side, this time .. next time the RWY is wet :\

[M2dude]

Errrr... every aircraft that I've ever been involved with has had NO AOG A/P inhibit. It's never been relevent before; no pilot I've ever known has been so daft as to even want and try and do it. As a previous poster pointed out, what in the world is a pilot doing messing around with the MCP on Take Off!!

[DJ77]

As I understand post #56, AF SOPs regarding A/T arming were changed after a 747 incident then were later reverted to the original Boeing procedure i.e. A/T armed at preflight.

I know the first change applied to 747s, 767s and 777s but does anybody know if the reversal also applied to the 777s

[The Snake]

"What is the philisophy behind being able to engage an AP during takeoff in the B777 design? Why isn't this feature inhibited until the minimum engage height?"

Interesting point. During my ATPL theory (2001...long time ago) they told me that modern integrated A/P can't be engaged on the ground. Surprised I was when switching from the BAe146 to the AVRO that it is still possible to engage everything on the ground.

Maybe as the A/P remains engaged during an Autoland until roll-out. The manufacture doesn't want to program altitude engagement limits in their autopilot?

[moonbase]

I heard the other day that there have been 7 incidents on the B777 of the autopilots being armed on T/O rather than the autothrottles - does anyone know where these figures came from or what the other incidents were?

[HotelT]

[M2Dude] .. every aircraft that I've ever been involved with has had NO AOG A/P inhibit. It's never been relevent before.On the MD11 one cannot engage the AP while on ground during takeoff, only the AT. If I remember correctly (it has been a few years since I last flew the MD11), the AP engage button ('Auto Flight' button) is used to engage the AT during takeoff ...

With -reportedly- 7 other incidents on the B777 (how many were not reported?) of pilots inadvertently engaging the AP i.s.o. the AT during takeoff, I would consider it wise if Boeing were to re-evaluate the MCP design (especially if other A/C-types have not shown similar mishaps; why did B744/B737NGs not have similar problems with their MCPs/APs ?). Boeing will probably get away with this incident; any future crash, Boeing will probably be (at least partially) liable.

Nevertheless, I fully agree that non-standard MCP (or Flap, for that matter) selections during takeoff should not be performed nor excused.

My two cents...

[safetypee]

The Snake, IIRC the Avro RJ autothrottle could be armed for take off and engaged by selecting TOGA. The autopilot could not be selected ON when on the ground (squat switches). During an autoland, the autopilot would remain engaged until 80kts where the crew should disengage it, but the system would automatically disengage below 60 kts.
The selector switches were dissimilar and provided an annunciation both at the point of selection (the switch) and in the mode display on the EFIS.

[Longhitter]

The Avro RJ autopilot can be engaged on the ground. It has to be disconnected by pilot action after an autoland as it will not disconnect itself.

[TyroPicard]

M2dude
Errrr... every aircraft that I've ever been involved with has had NO AOG A/P inhibit. It's never been relevent before; no pilot I've ever known has been so daft as to even want and try and do it.
You were never involved with the DC-10-30, then. AP engagement in Manual was permitted for takeoff - saw it done by one daft training captain.

[M2dude]

Wow!! that sure makes you think; I bet there were at least 2 other surprised guys on the F/D.
I've been going through the 777 APFDC A/P engage logic diagrams, and found that in spite of what was previously thought (certainly by myself) there IS a sort of A/P engage inhibit on T/O for the 777. Although you can engage the A/P on the ground, you can NOT if the G/S is above 80KTS with less than 50'RA. However with the A/P engaged there is still nothing to stop the pilot commencing T/O; a la Air France at LOS. The mind boggles!
:ugh:

[S.F.L.Y]

a la Air France at LOS. The mind boggles!This is certainly a more reasonable comment than the undocumented allegations you are making in the concorde thread with your Captnintendo dude.

[Max Angle]

Some aircraft do have an inhibit for AP engagement on the ground, namely the FBW Airbus family which prevents engagement until 5 seconds after take-off.

[M2dude]

Ah, ok..wasn't sure about the Airbuses Max Angle; thanks. I've checked the 747-400 engage logic diagrams abd there does not seem to be any such 777 equivilent. (Older design I guess).

[HotelT]

A/P logic is one thing, then there is the ergonomics of the B777 panel:

The B777 (http://www.airliners.net/photo/Air-France/Boeing-777-228-ER/0372661/L/&sid=9965dbd06faddce0860b108a20eb8e74) has two A/P buttons, on the (far) left- and the (far) right-hand side of the MCP (APFDC) .. and the A/P disengage bar smack in the middle. On the left-hand side, it is easy to make a mistake with the A/T button; on the right-hand side it is easy to mistake with the APP button. According to simulator instructors on the B777 mistakes are frequently made (especially with relatively new guys and galls), since all buttons are the same size and feel, only slightly different in text (even worse in night-like conditions, such as the departure ex-LOS, especially for the age 40+ drivers amongst us). If you compare that to the B744 (http://www.airliners.net/photo/Thai-Airways-International/Boeing-747-4D7/0240070/L/&sid=7c7d087dda61691a6e9e343a660976ee) (3 buttons on the right-hand side) and B737NG (http://www.airliners.net/photo/KLM---Royal/Boeing-737-8K2/0755461/L/&sid=586999bc2b26ee68d46cedd4236fba93) (4 buttons above A/P disengage bar), the main difference is obvious: the location of the A/P buttons.

All change is not progress...

[Phantom Driver]

Lot of hot air circulating here. Seems like many have forgotten the basic requirement (already pointed out by earlier posters in this thread), viz;....READ/ANNOUNCE THE FMA!!

I suspect quite a few operators aren't bothering with, or are ignoring, this aspect of glass cockpit ops. Please stop trying to lay all the blame on cockpit ergonomics and instead focus on our own shortcomings of not adhering to basic SOP's.

On two occasions, (early days on the 744), I mistakenly activated TOGA switches, once on the ground while taxiing for take-off, due to the bad habit-(very quickly discontinued )-of using the palm of the hands to bring all 4 thrust levers back to idle, which lead to pressure on the TOGA switches. The second time was on finals, manual flying, and brain seizure going for TOGA switch rather than A/T disconnect. All due to inexperience on the machine at the time.

However, the point I wish to make is--on both occasions there was absolutely no drama whatsoever; One is instantly aware of the uncalled-for spoolup (in the ground event,a surprisingly smooth affair; not sure if this a designed intent by Boeing engineers for the 74, as I haven't experienced it/made a similar c**k up on another type). PM called the FMA on both occasions to confirm what was happening; a quick prod of the correct button (A/T disconnect) instantly solved the problem. reset the FD's and business resumed as normal.

One wonders why AF, with allegedly similar occurrences, saw fit to make drastic changes to their procedures. Asking for trouble?

[DJ77]

HotelT, your are right, it's easy to confuse the left AP button with the A/T button.

However, the captain had no good reason to fumble with the MCP buttons since hitting the A/T button would have achieved nothing. It is inhibited below 400 ft RA.

Intentionnally or not (the report says the later), he hit the AP button while moving the A/T ARM switches after he realized he had omited them in the OFF position at preflight or before takeoff, depending on the current SOP.

To engage the A/Ts on the ground you have to arm them first, then push the TO/GA switches located forward of the throttle levers. Btw, these TO/GA switches are much less likely to be inadvertently activated than the palm swiches of the 747s so I believe that changing the AF SOPs was widely unjustified for the 777.

[HotelT]

I am not trying to excuse the captain for making non-std selections during takeoff, nor the F/O for not properly monitoring the FMA (although it would have probably taken him a while to compute; not only the totally unexpected FMA readings itself .. but especially the "CMD" -or 777 similar- annunciation). See also my earlier statement "non-standard MCP (or Flap, for that matter) selections during takeoff should not be performed nor excused".

The point I am trying to make is that I would like to know what can be done to prevent further (and worse) mishaps. Why did the captain make these selections in this flight phase? Why was it technically possible to engage an autopilot in a situation in which autopilot use is not intended nor certified? Why the mix-up in buttons? Etc., etc..

It is always easy to blame the pilot (and let me stress once more: I do not approve of his actions), but our training, procedures and technology are intended to provide extra layers of safety in order to prevent such mishaps. Blaming this captain might seem the appropriate (easiest?) thing to do (and maybe even convince ourselves that we are superior in operating aircraft and that these things will never happen to us), but experience has shown this course of action usually will not prevent future mishaps...

As for the hot air.. unfortunately the country I live in isn't as warm as SIN :(

[stanley]

There was an old DC10 saying which still holds true LIVE or DIE by the FMA

[Phantom Driver]

HT

According to simulator instructors on the B777 mistakes are frequently made (especially with relatively new guys and galls), since all buttons are the same size and feel, only slightly different in text (even worse in night-like conditions, such as the departure ex-LOS, especially for the age 40+ drivers amongst us). If you compare that to the B744 (http://www.airliners.net/photo/Thai-Airways-International/Boeing-747-4D7/0240070/L/&sid=7c7d087dda61691a6e9e343a660976ee) (3 buttons on the right-hand side) and B737NG (http://www.airliners.net/photo/KLM---Royal/Boeing-737-8K2/0755461/L/&sid=586999bc2b26ee68d46cedd4236fba93) (4 buttons above A/P disengage bar), the main difference is obvious: the location of the A/P buttons.

Understood, particularly relevant at the moment, as I am in the process of transitioning from the "Queen of the Skies" onto it's (slightly) smaller sister. Points taken; I must admit to searching for the correct buttons in early sessions, but surely this is to do with inexperience on the machine rather than ergonomics? I don't know if this was the case with our AF colleagues, but I do think the engineers have done a great job on the 777.

My concern, as pointed out by others, is that- there is no reason to deviate from basic SOP's and start fiddling with the MCP during the take-off roll, be you PF or PM. Jeez, my instructor just told me off for adjusting the cockpit panel lights while taxiing! Do it beforehand, he said; (fair enough).


especially for the age 40+ drivers amongst us

Indeed!:sad:

[Me Myself]

What a load of tosh really !! 40+ and you already consider yourself an ergonomic write off ? Pathetic !
The auto pilot and the ATHR, although really close, can in no way be mistaken for one another, even if you are transitioning from..........er........the queen of the sky ??? Good grief ! How old are you ??
One is your simple square knob when the other(s) are 2 big, popping out, enough levers. Unless you have fatal brain injuries, there is no way you can make that mistake...................unless you commit the unforgivable sinn of being hasty.
That's where you get bitten.
Trust me, that poor fellow has a lot of time on his hands to think about it now..........sitting at home and not by his own choice if you get my drift.

[Phantom Driver]

40+ and you already consider yourself an ergonomic write off ? Pathetic !



Suggest you re-read what I had to say regarding "ergonomics" with just a little bit more attention. I think the present discussion is about A/T and A/P select BUTTONS (identical in appearance and closely spaced), not A/T arm SWITCHES on the 777 (Air France SOP's notwithstanding).

No excuse for what the guy supposedly did,(ALLEGEDLY hitting A/P instead of A/T button); maybe only mitigating circumstances here, but no question that even those would be hard to defend.

As I stated-there is no reason to deviate from basic SOP's and start fiddling with the MCP during the take-off roll,

Which doesn't mean we haven't all been guilty of doing that at one time or other........?

[fdr]

HT, Fantom:

Interesting discussion, and the honesty is refreshing.


"How many things, both just and unjust, are sanctioned by custom!"
Terence (c. 185 or c. 195– B.C.), Heautontimoroumenos. Act iv. Sc. 7, 11. (839.)

After 7 previous events, AF and potentially ANZ's, it is fair to assume that the manufacturer will be looking at changes with some enthusiasm.

The matter of SOP's becomes moot (overstated, actually becomes probably far more important...) on far too many occasions as a direct consequence of the crews being humans; it is a natural human response to attempt to correct an error, particularly when one may realise it is likely caused by the individual. The sudden flicking of switches, contrary to SOP's, 2 crew philosophy and common sense is nevertheless all too often the outcome. This is an observation from a fairly wide spectra of operators, class leaders and laggers as well. The same behavior is exhibited by line crew, instructors in simulators, TRI's TRE's etc.... within my observational history. This includes multiple airlines within alliance(s).

(Assuming my observation has any relation to the normal industry behavior, then) the defence mechanism is to ensure that where the operation goes pear shaped, that at the very least the monitoring pilot conducts a review of primary operating criteria... aviate-navigate-communicate, including the basic stuff such as FMA status vs desired. It is natural that the operating pilot/"system switch flicker", will have an instantaneously increased workload due to the non standard processes he/she has gone through that result in taking the non standard action, which places them at a disadvantage in performing reliably a self analysis of their actions and it's consequences. More formally, the individual is confronted with a sudden awareness of a Situational Awareness Type I, II, or III slip, and that their mental model of the world is suddenly (and occasionally dramatically) proved to be false.

Perception (Level 1 SA): The first step in achieving SA is to perceive the status, attributes, and dynamics of relevant elements in the environment. Thus, Level 1 SA, the most basic level of SA, involves the processes of monitoring, cue detection, and simple recognition, which lead to an awareness of multiple situational elements (objects, events, people, systems, environmental factors) and their current states (locations, conditions, modes, actions).

Comprehension (Level 2 SA): The next step in SA formation involves a synthesis of disjointed Level 1 SA elements through the processes of pattern recognition, interpretation, and evaluation. Level 2 SA requires integrating this information to understand how it will impact upon the individual’s goals and objectives. This includes developing a comprehensive picture of the world, or of that portion of the world of concern to the individual.

Projection (Level 3 SA): The third and highest level of SA involves the ability to project the future actions of the elements in the environment. Level 3 SA is achieved through knowledge of the status and dynamics of the elements and comprehension of the situation (Levels 1 and 2 SA), and then extrapolating this information forward in time to determine how it will affect future states of the operational environment.

"Vigilance and Workload in Automated Systems
Joel S. Warm

William N. Dember

University of Cincinnati

Peter A. Hancock

University of Minnesota

INTRODUCTION
Active vs. Supervisory Control
Vigilance or sustained attention refers to the ability of observers to maintain their focus of attention and to remain alert to stimuli for prolonged periods of time ( Davies & Parasuraman, 1982; Parasuraman, Warm, & Dember, 1987; Warm, 1984, 1993). This aspect of human performance is of considerable interest to human factors/ergonomics specialists because of its vital role in automated human-machine systems ( Howell, 1993; Warm, 1984). As Sheridan ( 1970, 1987) noted, the development and utilization of automatic control and computing devices for the acquisition, storage, and processing of information has altered the role of the human operator in many work settings from that of active controller to that of executive or supervisor. Thus, in settings such as military surveillance, industrial quality control, robotic manufacturing, seaboard navigation, nuclear power plant operations, long-distance driving, and prodromal symptom monitoring in intensive-care units, observers must attend to a wide variety of displays for untoward events and take effective action when they are noted. As Parasuraman ( 1986) said, the responsibility for target detection in today's highly automated systems may be allotted to instruments and controls, but human operators are still needed when systems malfunction or unusual events occur. In some cases, such as aircraft and nuclear power plant accidents, vigilance failures can be disastrous."

"Fault Management in Aviation Systems
William H. Rogers

Paul C. Schutte

Kara A. Latorella

NASA Langley Research Center

INTRODUCTION
Fault management gone awry rarely has disastrous consequences in commercial aviation. The Boeing Commercial Airplane Group ( 1994) reported that 120 hull loss accidents with known causes have occurred over the last 10 years. Of those 120, 13 have involved airframe, aircraft systems, or power plants. Most of these involved older-generation aircraft. Improved fault management may have avoided some of these accidents, but probably not all. Systems on today's aircraft have tremendous reliability and built-in redundancy. Fault management is generally performed very well. But when a fault is not handled properly, people can die, equipment can be lost, and careers can be needlessly ruined. Human error, in this case mismanagement of faults, as pointed out by Rasmussen ( 1986), should be taken as the starting point rather than the conclusion of investigation. Human error can be caused by fundamental human attentional and cognitive limitations and biases, as well as environmental and contextual factors. Improved fault management must be grounded in an understanding of human performance and the operational environment in which pilots and automation together must perform fault management."


In the AF case, the basic event could be characterised as an omission of a procedural step, SA-I failure, which results in an operational abnormal condition, ATR fails to function. The operator identifies the failure, and takes either SOP+non SOP action, or just non SOP action, which results in the AP being accidentally engaged, a further SA-I error. The non standard activity on the MCP increases workload and reduces monitoring resources, and results in failure to pick the AP/SA-I error, and at rotate results in the behavior of the flight control system being erroneously identified as a flight control problem (arguable, there is a restriction of the flight controls, but the causation is incorrect AP mode vs a flight control system malfunction). Overall, the initial SA-I failure results in action that causes a further SA-I failure resulting in an SA-II failure and consequent SA-III failure.

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While an SOP and good training may act to dampen the enthusiasm of the pilot to flick switches, the greatest strength may well be in using the same SOP's and training for the monitoring pilot to have heightened awareness of their importance in breaking the event chain by responding to non standard procedures, and abnormal operational processes by checking the basic stuff.

Error Mgt.... as we remain human and therefore prone to mussin' up....

[and before that is taken as an admission of the design supremacy of removing the human from the loop, my Windows Vista locks up far too often to have faith in mankind's short term ability to design an infallible system...]


Titanic
August 1914
Challenger
Columbia
Windows
Mir-Progress
Mars Climate Observer
Hubble myopics



[B]"Error has no end." Robert Browning (1812–1889) Paracelsus. Part iii.

Resources:

Situational Awareness:
Situation Awareness Publications | Aviation | Medical | Military Systems | More (http://www.satechnologies.com/publications/)
Situational Awareness Knowledge Center (http://www.army.mil/armyBTKC/focus/sa/index.htm)


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[Five Livers]

"On VR, the captain who was Pilot Flying felt a heavy strength on the controls, and thought about the stabilizer jam. He estimated the aircraft was unsafe to fly."

Excuse me for being old fashioned but doesn't V1 come before VR?

[jurassicjockey]

How much control input do you utilise before Vr?

[Phantom Driver]

fdr;

A welcome and detailed analysis; hopefully will be taken on board by the more erudite members of this forum.

Good quotes; would also like to add one of my favourites-"Man has oft more need to be reminded than informed"-(with apologies to --Samuel Johnson?). History really does seem to repeat itself, because we are forever reinventing the same old wheel. Similar to this forum really (mea culpa), same points made over and over again, but few seldom take note.

aviate-navigate-communicate


This really is the bottom line, isn't it?

One more food for thought from a former Air Force colleague-"Fight like crazy against Complacency-the biggest killer".

[Capt. Inop]

Excuse me for being old fashioned but doesn't V1 come before VR?

Yup you're right. However the PF probably didn't have the time to make a post on Tech Log about how to solve the problem.

Sitting on the ground being a wise man is easy.