Kenya Airlines 737-800 crash in 2007. Lessons for Australian airline pilots.

[A37575]

Recommend reading of a thread on Rumours and News called “Kenya Airlines 737-800 Missing. Well, it wasn’t missing for long as it turned out. To be precise, it went in just minute and 42 seconds from lift off to oblivion. This happened in 2007 and the official investigation report has just been published.

The report is a huge file but the basics are the captain elected to take off into a CB at night (other aircraft opted to wait for the storm to pass but not this bloke). Then while attempting to engage the autopilot shortly after take off, he soon caused the aircraft to roll beyond 115 degrees angle of bank due obvious poor hand flying ability on instruments. From then it was curtains - with apparently the young first officer joining on the controls but in the wrong direction. No future in that

The circumstances of the Kenya Airlines crash are similar (apart from the CB), to the Eygptian 737 Flash Air crash mentioned in a recent issue of Flight Safety Australia. In that crash also, the captain also lost control shortly after take off on a night turning departure and the CVR showed he was still shouting for the autopilot to be engaged as they hit the water at 420 knots making a big splash. His instrument flying ability wasn’t too hot at all… One wonders if his instrument rating renewals were all done with the comfort of the autopilot doing most of the flying. Happens a lot in the RPT club in Australia.

Pretty good bet the cause of the recent crash to an Ethiopian Airlines B737-800, which went out of control shortly after take off and speared into the sea in circumstances similar to the other two crashes, will be found to be poor instrument flying ability. Mind you that may depend on who does the investigation and whether ethnic cultural mores influence the investigation. That investigation inquiry is still going on.

What are the lessons Australian pilots can learn from the above described accidents and numerous other similar accidents overseas caused by lack of instrument flying basic skills?

The most obvious is the knowledge that over-reliance on automation inevitably leads to loss of pure flying skills and subsequent under-confidence of one’s ability to handle instrument flying without the autopilot. Use it or lose it, comes to mind. This applies especially to new cadet pilots going straight from CPL graduation into the first officer seat of a modern turbo-prop or jet transport. Some Regionals take note…

[Servo]

A37575,

Ok I will bite first.

"One wonders if his instrument rating renewals were all done with the comfort of the autopilot doing most of the flying. Happens a lot in the RPT club in Australia."

Not too sure about you, but the last 3 RPT Airlines I have worked for only ask you to put the autopilot in once everything is under control, then for the actual approach, disconnect the autopilot and "hand fly" the approach.

I think your comment "Happens a lot in the RPT club in Australia" is an ill informed derogative statement, most probably based on what little you think you know.............

Servo

[Horatio Leafblower]

A37575

While not wanting to detract from the general thrust of your post, which in its intent appears laudable, your thread about Visual Circling (http://www.pprune.org/dg-p-general-aviation-questions/414214-visual-circling-procedure-imc-surely-not.html) and now your comments about RPT CIR renewals cause me to question:

1/. your level of professional knowledge, and
2/. your motives.

:confused:

[Sonny Hammond]

I reckon that A37575 has a point.

Sure, there are some holes in a comparison of 'other' nationalities hand flying skills and that of Ozzy's.
Most Ozzy's work up a ladder of experience (including lots of hand flying) to get into a boeing or airbus, and have a fundamental skill of hand flying.
In 'other' countries it isnt uncommon to go straight into the RH seat of a 737 and miss that chance to build the skill.

Apples to Oranges then.

But the point is to acknowledge there has been a drive by many major airlines to an increased use of automatics over the past decade and there is no question that this has lowered the proficiency of the hand flying skills in the flight deck.

This is acknowledged by many majors right now as they change their SOP's to allow for more hand flying. American and Emirates are two.

So, lets practice our hand flying more and NOT takeoff/land blindly into thunderstorms.
Another bad habit of oz domestic....

Sonny.

[john_tullamarine]

most probably based on what little you think you know.............
your level of professional knowledge

FWIW I know the OP well and know that the above comments are wide of the mark.

[ga_trojan]

One wonders if his instrument rating renewals were all done with the comfort of the autopilot doing most of the flying. Happens a lot in the RPT club in Australia.
Well the RPT club I fly for makes you do a raw data hand flown ILS every 6 months, and it is not unheard of to hand fly a NDB too (just for fun says the checkie...!)

You will also be pleased to know that plenty of captains hand fly in VMC 'just for fun'. And some even do it raw data!!!

This applies especially to new cadet pilots going straight from CPL graduation into the first officer seat of a modern turbo-prop or jet transport. Some Regionals take note…I think this is a lack of experience or ability not a degradation of skills, the two are totally separate issues. Probably why the septic tanks are trying to introduce a 1500 hour rule before you get into a regional airline.

[Angle of Attack]

A37575 thanks for the link, interesting reading.

Although the 737-800's autopilot is hopeless would not trust it ever, overspeeds, disconnects randomly and dont even get me started on the flight director, its as useful as an aircraft with an ADF with no NDB's around.

Your general jist is correct, so many SOP'S and directions which are basically hopeless, and basic flying neglected. I would not say most RPT pilots would not be lacking as you suggest though, most come through with fairly proficient skills and few go straight to a RHS in a jet compared to Europe for example.

[psycho joe]

Hey,

someone should start a thread on the benefits, or lack there of of hand flying modern jet aircraft, and the lack of manipulative skills, real or perceived. We could all rally behind the first person to extol the virtues of manual manipulation, and declare our unwavering loyalty. Thereby filling a deep psychological void within ourselves, in the desperate hope of being accepted as a peer equal in a group dynamic. Much like cave men beating their chests around a camp fire whilst telling war stories about the dying art of the hunt. Or Americans espousing patriotism. For those non genuflecting types with a differing opinion, we could label them unproffessional (sic). Thus adding to our sense of individual superiority within the group dynamic, and effectively establishing ourselves as the Alpha male. For added effect we could berate the next generation and reminisce about how good we were. Of course we'll all pretend that all of this is in the interest of aviation safety and nothing at all to do with masking feelings of insecurity and inadequacy that exist deep within our psyche.



..."GIVE ME AUTOMATION OR GIVE ME SCHADENFREUDE!"
joe crazyhorse.

[Offcut]

Read it again. Sadly, I think he may be right.

[Feather #3]

Certainly, there are elements of truth in PJ's post, as in any like comment on group dynamics.

However, I'm informed that "Loss of Control" is a rising statistic in hull-loss and despite any individual posturing, it's an extremely valid point of discussion!

G'day ;)

[thechap]

Having flown, yes as a pilot, for one of the big Antipodean airlines I can say, with confidence, that the initial post in this thread is dead on. . . depending on fleet. The hand flying skills are not only sub-standard but so is the lack of understanding of the automation itself. From the retorts I assume it is not true at all of the local large jet carriers, good for you guy's, but no need to berate anyone who, from what I can tell, is speaking from personal experience themselves.

As far as the psycho-bable about making ourselves feel better about what we do as a profession, it's just that, psycho-babble. We've had enough accidents worldwide, (Gulf Air etc. on the A320 too) and fortunately just incidents with the majors in our neck of the woods (if you do fly for them you'll know exactly of what I speek), to know better. I've seen pilots sit in their seat on a V1 cut and an overshoot, watch the aircraft do exactly the opposite of what it is supposed to be doing, mostly because of a lack of understanding of the FMA's and automatics management, and repeatedly say "Just let it do it's thing" while we broke air regs and almost crashed the "thing". This by the way with the instructor happily watching.

Sorry Psycho, but we're still issued pilots licences that assume we can fly the aircraft. I know the plane can fly a V1 cut, if it's managed properly of course (there are way's to kill us all with the AP engaged as well). For the flight standards people at an airline to allow every pilot to use the automatics in such a situation because "that's what they'd do in real life" is downright negligent. Can they guarantee me that if something happens while I'm sitting in the back of one of their aircraft that the pilot will immediately engage the automatics, properly? I think not.

It's an excellent point, and considering Airbus itself has issued a statement regarding the danger of degrading hand flying skills, I think a pertinent one.

[Tee Emm]

Having flown, yes as a pilot, for one of the big Antipodean airlines I can say, with confidence, that the initial post in this thread is dead on. . . depending on fleet. The hand flying skills are not only sub-standard but so is the lack of understanding of the automation itself. From the retorts I assume it is not true at all of the local large jet carriers, good for you guy's, but no need to berate anyone who, from what I can tell, is speaking from personal experience themselvesArticle 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.

[Pedota]

This report adds to the debate . . . from Airline Transport World.

Dutch Safety Board cites 'convergence of circumstances' in 2009 THY 737 crash

Airline Transport World
7th May 2010

The Feb. 25, 2009, crash of a Turkish Airlines 737-800 on approach to Amsterdam Schiphol was caused by a malfunctioning radio altimeter, a non-stabilized approach, poor reactions from the pilots and insufficient directions from air traffic control, the Dutch Safety Board concluded in its final report released yesterday.

Nine persons were killed and a further 120 injured after the aircraft crashed short of the runway during final approach. "That the accident could happen was the result of a convergence of circumstances," the board said. "These circumstances could only have resulted in the accident happening because of their mutual interaction."

While executing the approach by means of the ILS with right autopilot engaged, the 737's left radio altimeter showed an incorrect height of minus 8 ft. on the left primary flight display. This resulted in activation of the autothrottle's "retard flare" mode whereby the thrust of both engines was reduced to a minimal value (approach idle) in preparation for the last phase of the landing. Owing to the approach heading and altitude provided to the crew by ATC, the localizer signal was intercepted 5.5 nm. from the runway threshold rather than at least 6.2 nm., with the result that the glideslope had to be intercepted from above.

"This obscured the fact that the autothrottle had entered the retard flare mode. In addition, it increased the crew's workload," investigators noted. When the aircraft descended to 1,000 ft., the approach was not stabilized "so the crew should have initiated a go-around," the board said. The right autopilot (using data from the right radio altimeter) followed the glideslope signal. As the airspeed continued to drop, the aircraft's pitch attitude kept increasing. "The crew failed to recognize the airspeed decay and the pitch increase until the moment the stick shaker was activated," according to the report. "Subsequently the approach to stall recovery procedure was not executed properly, causing the aircraft to stall and crash."

The board said its investigation did not uncover a reason for the altimeter malfunction but stated that "the failure of radio altimeter systems in 737-800 aircraft has a long history." Boeing "reasonably" could have realized that the problem, particularly the effect on the autothrottle, could have had an impact on safety, it said. It is recommending that the manufacturer improve the reliability of the radio altimeter system and that it review its "approach to stall" procedures with regard to the use of autopilot and autothrottle.

The report also was critical of AMS controllers, who "must observe the procedures as they are described in the rules" and not engage in individual interpretation. "The given heading instructions did not enable the aircraft to be in level flight on the final approach track before intercepting the glidepath from below," the board said. "This is not in line with the ICAO guidelines for this type of approach."

THY said it disagrees with "certain aspects" in the DSB report, in particular two conclusions: "Approach stabilization is not a factor in the causation of this accident and it is claimed by the report that the crew could have recovered the aircraft after the stall warning was received. However, even though the crew promptly reacted, autothrottle kicked back unexpectedly. The second attempt by the crew, after disengaging the autothrottle, to advance thrust levers was successful but too late."

[psycho joe]

A37575, thechap, Tee Emm & Pedota are all in the inner circle with Tee Emm being the highest ranking in the social pecking order. The race to cut & paste is on.

As far as the psycho-bable about making ourselves feel better about what we do as a profession, it's just that, psycho-babble.
Comprehension not your strong point?

My point is that the subject of manual flying has been done to death & always ends up the same. The person who extols the virtues of hand-flying with the longest posts and the most passion wins; More so if it involves a story that denigrates someone for their lack of ability. Ultimately, these stories make us feel superior.

Don't believe me?

There's no professional contribution here. On decision making, weather avoidance, spatial disorientation, mode awareness (FMA awareness), CRM breakdown or potential aircraft unserviceability (aircraft had a tendency to roll to the right). Nix. :ugh:

[UnderneathTheRadar]

the Dutch Safety Board concluded in its final report released yesterday.

The ATSB wouldn't even have a preliniminary report out by now......


Back on thread, I'm reminded of the old joke:

q: How do you tell an experienced Airbus pilot from an inexperienced one?

a: The inexperienced Airbus pilot says "Whe the f*ck is it doing" whilst the experienced on says "oh, it's doing that again"


I'll get my coat....

[LeadSled]

psycho,
You have added precisely nothing to the subject, but I do hope you feel better, having vented your spleen.
Tootle pip!!

[Icarus2001]

A37575 thanks for the link Where is the link in the post by A37575?

[Capn Bloggs]

psycho,
You have added precisely nothing to the subject, but I do hope you feel better, having vented your spleen.
Tootle pip!!
And you added...?

Geez TM, we didn't need that. It amazes me that most (well, some?) line drivers know that there is a major problem but most managers don't. And for Airbus to now start saying we need to keep up our manual flying skills is the ultimate in hypocrisy. They are only saying that because pilots are now unable to control their jets when the fabled autos give up the ghost. The horse has already bolted, and a huge amount of targeted training will be required to get some of us back to a reasonable level of flying skills.

That 737 crew were just another victim of a flawed system. The Shiny New Toy pilots have a lot to answer for, IMO.