Afriqiyah Airbus 330 Crash

[411A]

In an airplane without autoland capability flying an ILS to bare CAT I minimums, say 200 foot HaTH DA and RVR 1800 in obscuration, is very demanding, more so than an NPA to say, 400 and 1

Could be for you personally aterpster, however I have never found this to be the case.
I expect that many younger pilots whom have never been trained on dive/drive techniques, may well have a similar opinion as yours.
Now we have another Airbus FBW aircraft accident (see other thread re: ISB A321), also apparently during an NPA, this time circling.
I would suggest that rather basic flying skills are being forgotten at an alarming rate, in favor of the constant use of automatics, with the result that....the accident rate has not improved much, if at all.
IE: one set of problems has been exchanged for another, without much benefit.

[henra]

the accident rate has not improved much, if at all.
IE: one set of problems has been exchanged for another, without much benefit.


Hmm, I don't want to sound harsh but simple reading of the accident statistics for airliners over the last 4 decades would have told you otherwise.
significantly.
Safety has increased incredibly since the days of 707 and DC8.
You might want to try ASN for example.

Moreover it's not always lack of talent that kills when flying NPA.
Often it's complacency or overconfidence (It's gonna work...).

Yes you are absolutely right: automation is no excuse for lowering training standards or neglecting basic flying skills.
But I would rather wait for the result of the investigation (CVR should give a good hint) before jumping to conclusions

[411A]

Safety has increased incredibly since the days of 707 and DC8.

Yes it has, only because the reliability of the machinery (aircraft) has improved.
Pilot performance...not all that much.
We still have CFIT, as a major contributory factor.
A bad sign, IMO.
And further, it is not likely to change for the better, as long as we have poorly trained pilots.
Especially, in the RHS, with the P2F scemes now in vogue in Euroland, and elsewhere.

[safetypee]

411A, those that do not have the skills to fly these NPA's in a reasonable manner

Surely, the highest skill is that of thought – being able to choose a suitable option, selecting the lower risk, or utilise risk trapping / mitigating aids. You can still use your hands-on skills to fly an accurate, altitude / distance aided, NPA.
Citing the lack of skill is tantamount to allocating blame.

Many pilots stop their decision making on reaching the first condition that will work without considering a lower risk option. There is unlikely to be a perfect option, but too often, you hear that ‘it’s good enough’; it (NDB approach) may be good enough, but this choice requires skill in judging a better option for the situation (one with added safeguards) and not the minimum option.
Judgment is a quality of airmanship, professionalism, expertise; it represents the highest level of human need – self actualization (Maslow’s hierarchy of needs). Stopping the decision assessment at the hands-on skill level may only satisfy self esteem – the search for respect from others, is this your need; this is not good enough in today’s complex industry.

Lest I be accused of blaming crews because of poor ‘airmanship’, the thinking, evaluation/choice process is affected by many human factors; we have to understand these as part of an accident investigation. Accidents don’t just revolve around people’s abilities, it’s more often the external influences which tip the balance beyond acceptable behavior.

[BandAide]

I was born on the 707 (8,000 hours) and DC-8 (4,000 hours). For the last 4 years I've made my living on the A320.

The difference is that the old airplanes required direct involvement, planning, and minute by minute awareness in marginal weather or operational challenges. Flying approaches to minimums produced moisture in the palms of your hands.

Today's airplanes, like the A320, only require involvement by exception. You have to change a runway, you are assigned a different arrival - irritants. Most flights are lazy processes of doing what's planned and programmed.

The challenge now is to be ready to do the unexpected, manual, airplane-flying required by unanticipated situations.

[Stall Inducer]

I submit that regular crashes are now just part of the "lo co" business mod
That’s a bold statement
Ethiopian - not a loco
Kenya Airways - not a loco
Gulf Air - not a loco
Lets add some more - Air France A340 runway over run in Canada - a loco?
AA in Jamaica?
I think it's a wider problem than saying it's part of a loco business model.

[Neptunus Rex]

411A
You speak of P2F in "Euroland and elsewhere."
P2F is alive and well in the US of A. I had occasion to enquire about training on behalf of the son of a friend, and the school offered various P2F packages at the end of the CPL course. However, they were smart. Where they advertised training on a local airline, on closer scrutiny it transpired that the training was on the same type that carried passengers, but would be done hauling freight, mostly at night.
Caveat emptor.

[Taildragger67]

Do we have a cause of this crash yet?

[Mister Geezer]

Feel free to call me a sceptic, yet I suspect that the Libyans will deliberately take far longer than necessary to publish their findings. If the finger points to any deficiencies within the airline and/or human error, the Libyans will not want this information to be circulated. Whilst Libya has reformed from the dark days when it was allegedly linked to terrorism, it is still far from being a State where information is circulated freely. Whilst other organisations will be assisting in the investigation, I am sure the Libyans will not have relinquished their right of leading the investigation and subsequently publishing the findings.

Not only is a loss of face in the Arab world one of the most embarrassing things someone can endure, the Libyans will be petrified that Afriqiyah's future expansion will be hindered by anything negative that may arise from any findings.

There is also a conflict of interest here since Afriqiyah is owned by the government and the CAA in Libya is.... wholly owned by the government. Post accident investigations are supposed to be fully independent and impartial. The Libyan investigation can only be described as an 'internal' investigation, with some external assistance! Having worked in Libya previously and for a Libyan operator (not government owned!), I would not be at all surprised if the Libyan investigation team are all on first name terms with the senior management in Afriqiyah (most of whom have been in aviation since the pre sanction days with Libyan Arab or Jamahiriya Light Air Transport.).

Having read the brief summary given by Phil Squares on the previous pages, such a combination of possible factors are not what Afriqiyah and the Libyans will want to hear. However if CRM issues are to play here then Afriqiyah cannot be directly blamed since the LCAA framework for CRM training is somewhat laughable and is decades behind industry standard.

[desertson]

I was just there a couple of days ago... Debris field is mostly still there and partially packed up. Some people seemed to be doing something official there... Area widely cordoned off... Heartbreaking event!

[arc-en-ciel]

From Airbus safety magazine....December 2007 !
http://img409.imageshack.us/img409/5769/funnynpa.pdf

A pré-Afriqiyah ?

Reported event
The following was reported to Airbus:
“This flight was uneventful until the approach phase that was a non precision approach performed in VMC conditions. Weather report indicated a partly cloudy sky with 10 miles visibility at destination, but, during the descent, ATC informed the crew about variable weather conditions due to banks
of fog closing and opening the station. On final approach, due to low visibility, the crew initiated a go-around and hit electrical lines. The crew then diverted to the scheduled alternate airport.”
The investigation performed on site revealed that 25ft high electrical lines, located perpendicularly to the runway axis, at about 1100m from the runway threshold, were found sheared.
The aircraft was damaged subsequently to the impact with the electrical power lines. Damage was present all across the aircraft (fuselage, engine, wings) indicating that the aircraft impacted the lines head-on. Furthermore, some pieces of electrical lines were found in the area of the nose landing gear and it was concluded that the initial impact occurred at nose landing gear level.


With a mix of trust Levers not at TOGA incidents = .... ??? Tripoli accident?

[Capn Bloggs]

On final approach, due to low visibility, the crew initiated a go-around and hit electrical lines.
Do you Scarebus pilots set the MDA until commencing the Missed Approach?

That would have stopped that crew descending below the MDA whilst still in Autoflight.

[arc-en-ciel]

The story in more details :

3 DFDR analysis Note: for de-identification reasons altitudes are
given in heights with reference to QFE.

This was a step-down VOR-DME approach conducted in daylight, early in the morning, autopilot engaged.

As a consequence, the approach was a succession of descent and level flight phases so that autopilot longitudinal modes were alternatively OP DES mode and ALT*/ALT modes, while the auto-thrust modes were respectively idle mode and speed mode (with speed managed by the FMS). The successive constraint altitudes were fully respected.
Shortly before over-flying the last altitude constraint “P1” (859ft QFE situated at 3.7NM from the runway threshold) the aircraft was in level flight at 860ft QFE. The minimum descent height was 459ft.
The figure here below presents the descent profile from “P1” This sequence can be detailed as follows:
• Shortly before over-
flying “P1”, MDA altitude was selected on the FCU, and the OP DES longitudinal autopilot mode was selected so that a thrust reduction was progressively commanded to target idle thrust, while the autopilot pitch mode maintained the speed target.
• At that stage the aircraft was in slats/flaps configuration 3, gear down, both flight directors engaged, autopilot N°2 engaged.
• For the whole approach the autopilot lateral mode remained in NAV mode.
• At 800ft QFE, 3NM from runway threshold, shortly after over-flying the last altitude constraint “P1” full slats/flaps configuration was selected.
• At 680ft QFE, 2.6NM from runway threshold, whereas the rate of descent was 1000ft/min, an altitude 300ft below MDA was selected on the FCU.:ugh:
• At 600ft QFE, 2.3NM from runway threshold, while the current rate of descent was -1400ft/min, the crew selected the autopilot V/S mode with initially a selected V/S of -700ft/min. From that time auto-thrust was therefore engaged in speed mode. Target speed was Vapp (VLS +5kts).
• While descending below MDA about 2.1 NM from runway threshold, go-around altitude was selected on the FCU.
• At 325ft QFE/ 1.54NM from runway threshold, the crew selected a vertical speed of - 800ft/min.
• At 47ft RA at about 0.72NM from runway threshold the crew selected a vertical speed of
0ft/min.:=
• At 35ft RA, at 0.70 NM from runway threshold,
the Pilot Flying applied 2/3 of full back stick input that disconnected immediately the autopilot. :}

Notes: 1/ As this approach was
performed in GPS primary (In this case only GPS and IRS data are used for the aircraft position computation) the accuracy of the recorded aircraft position is very good.
2/ In managed guidance only (FINAL APP mode engaged) when the aircraft reaches MDA (MDH) –50ft or 400ft (if no MDA/MDH entered) the autopilot automatically disengages.
3/ As noticeable on the figure here above, from MDA altitude this final descent was performed on a 3° slope.

http://img825.imageshack.us/img825/1459/electriclinesapproach.pdf

The figure here below presents a zoom on the pilot’s take-over phase: • The radio-altimeter parameters recorded in the
DFDR (here plotted in red ) indicate the distance between the lowest point of the main landing gear and the ground.
• The initial PF’s pitch-up stick input was followed by permanent pitch-up stick input (between 1/3 and full back stick input) applied for 6 seconds, so that the aircraft stopped descending and started to climb.
• Minimum recorded altitude was 5ft RA reached at about 1100m from the runway threshold. :eek:
Zoom on pilot’s take-over phase
• The estimation of the impact location indicates that, at that moment, the aircraft impacted the electrical lines.
• At 10ft RA, 4.5 seconds after the initial PF’s pitch- up stick input, thrust levers were moved forward to TOGA detent.:rolleyes:
• 43 seconds after TOGA application, landing gears were selected up.:bored:
• 2 minutes after TOGA application, Slats/Flaps configuration 3 was selected.:E
• The aircraft diverted to the scheduled alternate airport.:D

PS : this is NOT the Afriqiyah event, but a very similar event that occured in 2007

[Capn Bloggs]

At 680ft QFE, 2.6NM from runway threshold, whereas the rate of descent was 1000ft/min, an altitude 300ft below MDA was selected on the FCU.
• While descending below MDA about 2.1 NM from runway threshold, go-around altitude was selected on the FCU.

That answers my question (at least in that case). :cool:

[arc-en-ciel]

Capn Bloggs,

Answer is
http://img190.imageshack.us/img190/4662/mdaslection.pdf

But it depends if you follow Airbus recommendations ....or not :mad:

[valvanuz]

Quote:
...the investigation performed on site revealed that 25ft high electrical lines, located perpendicularly to the runway axis, at about 1100m from the runway threshold, were found sheared...

... Furthermore, some pieces of electrical lines were found in the area of the nose landing gear and it was concluded that the initial impact occurred at nose landing gear level...


WOW! Still in a pitch or near down attitude! Little time and space left to find the way out!

[Capn Bloggs]

Ah ha. So even if they had followed Airbus recommendations, the 2007 incident could still/probably would have occurred.

I find it odd that Airbus worries about destabilising the approach by entering ALT* (I assume this is altitude capture) approaching the MDA (if it was set on the FCU). What's the issue? The aircraft is levelling at the MDA. You are not allowed below the MDA. Is Airbus suggesting you set the Go Around altitude at the FAF so that you can go below the MDA? Surely the idea is you don't go below the MDA unless Visual, in which case you just pickle off the AP and continue? If the autoflight has already started to flare at the MDA, tough. Go Around.

Although, I suppose setting the GA altitude at the FAF makes it easier to "cheat"... provided you don't hit the ground in the process. :ok:

[aguadalte]

On final approach, due to low visibility, the crew initiated a go-around and hit electrical lines. Do you Scarebus pilots set the MDA until commencing the Missed Approach?

That would have stopped that crew descending below the MDA whilst still in Autoflight.

Airbus Procedures ask for Go-Around Altitude Selection on the FCU, (not MDA).
MDA is selected on the FMGS's Approach Pag.

This is the way the system is conceived. You can bring down your aircraft with AP ON until MDA. If, and when you reach MDA -50ft, AP will disconnect and FD mode reverts to basic HDG/VS.

The ILS lookalike approach will bring you to a point where a pilot (does not need to level-off and) may continue the approach (if visual) or has to execute a GA.
Quote:
At 680ft QFE, 2.6NM from runway threshold, whereas the rate of descent was 1000ft/min, an altitude 300ft below MDA was selected on the FCU.
• While descending below MDA about 2.1 NM from runway threshold, go-around altitude was selected on the FCU.
That answers my question (at least in that case). http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/cool.gif

Right. This is particularly the wrong way to make an NPA.

[Capn Bloggs]

Aguadalte, thanks for that. Except that the AP will only disconnect at MDA -50 if in managed mode:

2/ In managed guidance only (FINAL APP mode engaged) when the aircraft reaches MDA (MDH) –50ft or 400ft (if no MDA/MDH entered) the autopilot automatically disengages.

Except that they were in VS from 700ft down. They had no FCU altitude protection. If they been in managed mode initially, surely they would not have been 200ft below the 3° path when they went to VS?

[aguadalte]

I agree with you.
I believe [that in this particular case] his intentions were to brake minimums, with AP ON...so he elected to fly "selected".
Some guys, never learn, or learn the hard way...

[arc-en-ciel]

there is no info regarding the lateral mode used for the approach, hence it could have been NAV/VS or HDG/VS, (so either managed lateral/selected vertical, or selected lateral/selected vertical).
as the a/c was GPWS equipped, the NAV function should have been quite/very accurate. there is no mention about any lateral deviation.

On the other hand
http://img828.imageshack.us/img828/2061/canpaairbus.pdf
and also
http://img337.imageshack.us/img337/103/canpa.pdf

Not only the operator does not cares about Airbus recommendations but also it's CAA...:hmm:

[mike-wsm]

Posted in support of arc-en-ciel's quote from Airbus Safety Magazine #5 December 2007.

http://mjr.org.uk/pprune-017.jpg

http://mjr.org.uk/pprune-018.jpg

http://mjr.org.uk/pprune-019.jpg

[aguadalte]

Here's another misled use of auto-flight systems. A Go-Around initiated without TO/GA selection, (FLEX/MCT selected instead) that could have gone very wrong:
Report: Air France A319 at Paris on Sep 23rd 2009, go-around . (http://avherald.com/h?article=4319fdab&opt=1024)

[411A]

The difference is that the old airplanes required direct involvement, planning, and minute by minute awareness in marginal weather or operational challenges.


So very true, without exception.

Wonderbus types.. th.note same, it would appear.

[BOAC]

Indeed - and in fact it appears that this should (for Airbus) read - planning, and even more minute by minute awareness in marginal weather or operational challenges. . It all seems to be about 'mode confusion'.

[Ice Age]

Do anyone know the name of the Co-Pilot? Was it a lady?

[Jabiman]

Captain Yousef Bashir Al-Saadi, Co-pilot Tareq Mousa Abu Al-Chaouachi, and Co-pilot Nazim Al-Mabruk Al-Tarhuni.

All were male.

[Swiss Cheese]

I wanted to commend C-SAR for his sterling efforts to get reliable data to this forum, it really is above and beyond, in the circumstances. Well done.

Whilst the official accident report is of course awaited, itself a melange of politics, facts and commerce, I would like to attach a fairly contemporaneous photo of the throttle quadrant. It makes for interesting viewing.

Trouble is, I cannot work out where the attachment icon is - I did try to copy and paste, but failed miserably. Help!

[BOAC]

http://www.pprune.org/spectators-balcony-spotters-corner/203481-image-posting-pprune-guide.html

[RegDep]

Swiss Cheese

If (just if) you wish to save the effort and want someone to post your picture(s), may I suggest that you PM some PPRuNer (including me, if you wish), who would be happy to post them for you, in the interest of the thread.

[mike-wsm]

Posted for Swiss Cheese:
http://mjr.org.uk/pprune-021.jpg
full size 786x1024 (http://mjr.org.uk/pprune-022.jpg)

[PJ2]

Swiss Cheese;

Many thanks for this. Here is a graphic of the pedestal as installed. The red rectangle area is the section shown in the photo. The blue section is the lower FMGC panel, the speedbrake handle and the parking brake handle panels behind and to the left of the thrust lever/engine switch panels:

http://batcave1.smugmug.com/photos/1101819223_yzmvj-L-2.jpg

From the photo we see the EIS Switching Panel, the ECAM System Display Control Panel, two thrust levers at the IDLE position, two trim wheels, the fuel control switches without the guards and engine fire lights. Missing are radio panels outboard of the trim wheels, the trim indicators themselves and the aft portion of the pedestal except for one FMGC panel which is resting to the left of the pedestal.

If I may ask, do you have any further photographs of the nearby wreckage? The outboard portions of the quadrant as described, are missing; they would be able to supply a bit more information; hopefully those doing the investigation are already well beyond this kind of information, however.

PJ2

[BOAC]

Swiss - in itself it does not say anything other than the throttle levers were at idle IN THAT PICTURE. Where they were at any other point will come from the fdr.

[Swiss Cheese]

Yes, on a strictly physical evidential basis, you are correct. However, inferentially, you could hypothesise that they were commanded at idle, and the impact forces did not dislodge them from that idle position.

Since there has been deafening silence from the Libyans, this forum is one of the few where informed speculation can be of general assistance.

The new EU regulation on accident investigation that was published in the Official Journal of the EU on November 12th this month, will alter the nature of such investigations to make them more accessible,

Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC (1)

[glad rag]

The above photograph shows an item of equipment that has been damaged it would be quite an assumption to try and say that any of the positions actually relate to anything pre impact due to said damage and witness marks/dirt embedded.

[BOAC]

However, inferentially, you could hypothesise that they were commanded at idle, - generally an unwise assumption, although of course possible. I understand you practice law? Would you expect a conviction based on that photo?

You need to imagine what convolutions/tumbles/impacts/human actions might have occurred immediately before and after impact.

[CONF iture]

However, inferentially, you could hypothesise that they were commanded at idle, and the impact forces did not dislodge them from that idle position.
You could hypothesize so many things ie how both fuel control switches disappeared.
How long between the crash and that picture ?

[Swiss Cheese]

In the Court of Pprune, if something is more probable than not, or 50.01% for those with a maths preference, then that could be regarded as more than a rumour, and quite possibly a fact.

In Civil Courts, that is the same evidential standard of proof - whether in the UK, US, South Africa or Australia.

Criminal Courts generally require a standard of evidential proof that is beyond reasonable doubt, again well north of 75% for the maths minded.

No one here is asserting any hypothesis for criminal behaviour on behalf of the crew. Most of us know the chilling effect that this would have on air safety. Better a safety culture than a blame culture.

So, a potential partial hypothesis is that the crew commanded idle from the engines......

[BOAC]

So, a potential partial hypothesis is that the crew commanded idle from the engines...... - yes, of course, but extremely 'partial' and with little 'potential', I fear.

[RetiredF4]

CONF iture
You could hypothesize so many things ie how both fuel control switches disappeared.
How long between the crash and that picture ?

If you zoom in on the picture, one could assume it was taken at the crash site. To the upper left there is ground visible. The red colour comes from plastik bags with some part of a flower or a olive-branch in it, like bought in a flower shop. Either those had been dropped as mourning greeetings for the crew or they had been carried on the airplane or in the cockpit.

However i dont think from the complete arrangement that it was taken in the flight safety shop.

The missing engine fire lights........... no idea. Could it be that those are fixed mainly on a frame below the panel and only the covers themselves sheared off?

There might be markings on the throttle quadrant and the linkage which can tell the position of the throttles at first impact, however not visible on the picture.

Thanks for the picture, are there more available?

franzl

[HundredPercentPlease]

The exif data for that photo shows that it was taken 3.5 days after the crash.

[Blocksoff]

Were are the black boxes?

[aterpster]

Blocksoff:

Were are the black boxes?

I believe it was discussed quite early in this thread that they were sent to France, but that France was bound by a non-disclosure agreement.

[V1... Ooops]

...France was bound by a non-disclosure agreement...

Yeah - the agreement states that France won't disclose anything that might reflect badly on French industry. :E

[noske]

Since there has been deafening silence from the Libyans,I would like to point out that at least Afriqiyah are still updating their page on flight 771. The last entry is dated Nov 12, it cites annex 13, lists the participating agencies, and says that a final report "is awaited". :ok:

Flight Afriqiyah Airways 771 Johannesburg - Tripoli (http://www.afriqiyah.aero/about-us/flight-8u771.html)

[Giolla]

Today, a Dutch daily (Algemeen Dagblad) released a general concern of familymembers of the perished passengers. For a long time no more news, and, above all, not a single item of the personal belongings/luggage have been returned yet according to their claim of today.
A British company has been requested to catalogue the particular unidentified items, sofar nothing has had any positive result.
The concerned party of familymembers meanwhile instituted a foundation to protect their interests to keep the Libyan Airline ahead of the fact that the case is still not closed.

[Brain Potter]

It would be interesting to know if either the aircraft involved in the near-crash as described by arc-en-ciel (page 64) or the actual accident aircraft had the QFE pin-program installed.

Two things lead me to ask the question.

1. The report and graphics that arc-en-ciel has posted refer to QFE.

2. Phil Squares (Page 61) appears to have been privy to the accident DFDR data and indicates that an intended managed approach was changed to selected at a late stage.

The Airbus QFE pin-program sees the MDA (ie "baro minimum") field in the MCDU permanently changed to MDH irrespective of whether QFE or QNH is set. When flying a QNH-based selected NPA the applicable MDA is inserted in this field but is displayed labelled as "MDH". However, when flying a managed/managed NPA the associated MDH must be inserted into this field, irrespective of whether the approach is to be flown on QNH to an MDA or on QFE to an MDH. If this is not done correctly the "triple-click" and mode reversion will occur at the wrong altitude. This set-up makes it quite awkward to change from a managed/managed to a selected approach, without having an incorrect MDH in view, with associated erroneous or missing auto-callouts.

[Mister Geezer]

Lufthansa to carry out an audit of Libyan Airlines and Afriqiyah which, apparently includes screening all flight crew in the sim.

Libyan & Afriqiyah Airways Embark on Flight Safety Assessment (http://allafrica.com/stories/201101070541.html)

[RoyHudd]

Good news for all concerned. Although LH have had their moments too....

[aguadalte]

Cesco:
Read the article...its all there.

[lomapaseo]

There is a big difference between one airline auditing another and commisioning an audit by an independent body.

Audits are done by experts in safety matters and not by corporations with broader interests.

[V1... Ooops]

Does anyone know when the accident report will be ready?

[Yellow Pen]

There's not necessarily anything wrong with one airline auditing another. Delta pulled few punches in their report on Korean a few years back.

[henra]

LH auditing them is definitely good news.
I wonder why some are questioning the coice of LH.
They are definitely among the absolutely best airlines when it comes to safety.
Yes you could have probably chosen a hand full other airlines equally well, but probably not really better by any standards.

You may disucss their approach to Customer Service but concerning the hard facts of flying they are among the best.

[grimmrad]

Could you enlighten me to what these moments were (I use LH as SLF quite frequently)...?

[XLNL]

From the article above:
"Lufthansa Consulting will evaluate each pilot and identify development potential."

You got to love the wording used...

And I read:
"The program, scheduled to take three months..."

So I don't expect a report anytime before that. Although this news might not seem directly related to the accident it wouldn't surprise me if this program will fullfill one of the recommendations in the -still to be published- accident report, box ticked, continue as before...
(all a wild guess/speculation of course...)

[ATC Watcher]

Good point for the Lybians, you need guts to do an audit like this. I wished more airlines /CAAs had the same guts. Now of course the main point is what you do with the results .

Although LH have had their moments too

Every airline had their moment, what is important is how you deal about it.

I know a few Ops Training and Safety depts and one thing is for sure, they are one of the best . No question.

.

[Shell Management]

I agree with lomapaseo.

There is a real danger of just getting a training soloution that looks like LH's but doesn't cope with the local realities.

LH Consulting certainly failed in their assignment to transform the Brazilian offshore helicopter industry.

[vanHorck]

Complaints on Dutch NOS TV news from relatives of victims of the Tripoli crash that they hear nothing about the investigation. The intermediaries too are despairing about the lack of information according to the same report

[aterpster]

Complaints on Dutch NOS TV news from relatives of victims of the Tripoli crash that they hear nothing about the investigation. The intermediaries too are despairing about the lack of information according to the same report.

Sadly, this is not surprising at all.

[411A]

Complaints on Dutch NOS TV news from relatives of victims of the Tripoli crash that they hear nothing about the investigation
Are you really surprised?
Let's face facts here.
That NDB approach to runway 09 at TIP is certainly not the most difficult of NDB approaches (two beacons) and although the VOR approach to the same runway is slightly offset, the offset as I recall is in the other direction from where the wreckage was found.
I've personally completed that approach numerous times, yes, even in the early morning sun.
This crew, for whatever reason, apparently had severe difficulty...perhaps by using automatics when they were not especially appropriate for the conditions.
So, LAA have asked for an audit of their ops.
Don't be at all surprised if no results are released, nor acted upon.

[vanHorck]

Perhaps one day somebody will leak the FDR data.....

[aguadalte]

Cesco: What determined LH to be the suitable auditor?
Fom the article: allAfrica.com: Nigeria: Libyan, Afriqiyah Airways Embark on Flight Safety Assessment (http://allafrica.com/stories/201101070541.html) The Libyan African Aviation Holding Company (LAAHCo) and Lufthansa Consulting have signed an agreement focused on the safety standards of Libyan Airlines and Afriqiyah Airways.
Its a Libyan decision. An agreement signed between both parties. Nothing more, nothing less than that. And a good move by the Libyans in my point of view, although without the institutional weight of an audit done by some international authorities, but a good corporate governance move anyway.

[Chiclets]

Why LH? Easy. Someone behind a desk down there has his fingers deep down in the LH Training jar and saw a chance to increase his pension a bit. :=

[A-3TWENTY]

Why such a surprise for beeing audited by Lufthansa? It`s good.

Korean Air years ago was probably the most dangerous company in the world with almost a loss a year. They were audited by DELTA and since then things to go smoothly.

If you don`t know , ask for help.

[Goat Whisperer]

Wasn't Korean flt ops turned around by Boeing-hired instructors?

I met some in Seoul, the horror stories stick with me.

[aterpster]

A-3Twenty:

Korean Air years ago was probably the most dangerous company in the world with almost a loss a year. They were audited by DELTA and since then things to go smoothly.
The KAL 747 crash in Guam was an NTSB investigation. The hearing was held in Honolulu (1998). I was a participant in that hearing. The insights were significant, to say the least.

[Mister Geezer]

If the decision to involve LH was a 'Libyan' decision from the outset, then they are to be applauded. However if it is not, then it would be certainly be fascinating to learn who has turned the thumbscrews. The possibilities are perhaps endless.

Does anyone know when the accident report will be ready?

You will certainly not be seeing any investigation report and any findings will be kept as confidential as possible. The Libyans were very keen from the outset, to retain executive control of the investigation and not relinquish their oversight. This was undoubtedly done, so that they can control how information is circulated, or not as the case may be.

Further more, the investigation simply cannot be classed as independent and impartial. Afriqiyah and the LCAA are both Government organisations, so the whole process is therefore more of an 'internal inquiry', than a formal investigation. Also bear in mind that the upper echelons at Afriqiyah and the LCAA, will most likely be on first name terms with working relationships that date back long before Afriqiyah existed. As someone who used to fly for a Libyan operator, I can certainly vouch for the fact that the Libyan aviation community is incredibly close knit.

[jcjeant]

Hi,

Further more, the investigation simply cannot be classed as independent and impartial. Afriqiyah and the LCAA are both Government organisations, so the whole process is therefore more of an 'internal inquiry', than a formal investigation. Also bear in mind that the upper echelons at Afriqiyah and the LCAA, will most likely be on first name terms with working relationships that date back long before Afriqiyah existed. As someone who used to fly for a Libyan operator, I can certainly vouch for the fact that the Libyan aviation community is incredibly close knit.It seems to me that this is exactly the same situation exists in France (from a few small differences) .... but I disgress ... of course :8

[411A]

It seems to me that this is exactly the same situation exists in France
Ohhhh, say it isn't so...:{:{:rolleyes:

[CONF iture]

Pretty same stuff anywhere 411A

SXKOEAfHO-c&feature=player_embedded

[ATC Watcher]

Thanks for that video-reminder Confiture ! The last mimic of Bourgeois says it all. . For those that do not speak French, Bourgeois was the Chief Investigator in 1979,and was told by his superiors not to make reports on 2 previous Concorde accidents because it was AF, and " we're not going to bother Air France " he said.
The big question is : is what was possible in the 70s still valid today ?

[DozyWannabe]

The big question is : is what was possible in the 70s still valid today ?

Probably not, because since then there have been too many incidents where soft-pedalling reports for the sake of national pride or corporate well-being have been more trouble than they're worth.

[CONF iture]

Probably not, because since then there have been too many incidents where soft-pedalling reports for the sake of national pride or corporate well-being have been more trouble than they're worth.
Which reports do you have in mind DozyWannabe and what have been the troubles that played against their initiators ... ?

What was valid in the 70s was also valid in the 90s is still valid in 2010 and will dominate in 2030.

[fdr]

Throttle Position Inferences-Limitations


While interesting in relation to the local level of destruction, the photo of the thrust levers is not evidence per se of the thrust commanded at the point of impact. The levers may not be in the position that they were post accident, policing of the accident site is evidently questionable, and they may have been moved. The quadrant has evidently been disassociated from the control system and has been subject to high external forces. As such the other components it may have encountered as the cockpit was destroyed may have repositioned the levers from any commanded position. There are on occasions witness marks that can be identified with the major forces that have been encountered, but they may not have been at the time of initial impact, but later for this part of the airframe. These marks if evident would not be indicated in an overview image as provided.

The evidence of the thrust level will come from the DFDR/QAR/DFDAU, EEC's memory and can be identified from the CVR. These sources can also indicate if a command change was initiated immediately prior to the impact.

Overall, not seeing that the industry knowledge base is going to be qualitatively expanded from this event, the overall event is shaping up as a repeat of operations that have resulted in near misses and accidents in the past on various types, not just Airbus products.

Separately, why the profession and industry allows the operation of such approaches given the historically identified elevated associated risk is perplexing. While I am certain that 411 (no disrespect) can fly a perfect approach like this every day, the industry shows that it doesn't on average cope well, and as a consequence, people die. The industry suffers from the malaise of the lack of appropriate infrastructure for hi capacity RPT operations, and lax operational oversight to ensure that the operations comply with the appropriate restrictions that would be applicable for such pitiful facilitation. This is not a Libya centric issue, this exists in irrational operations at airports such as Zurich, Amsterdam, Sydney, Auckland, Narita, Chicago etc.

Easy to bag the dead pilots for the failures of the regulatory and operational programs that are sitting around the campfire singing "Kumbaya" while next of kin bury the dead. Their problems though, are over, and the risk to the passengers remains due to the lack of investment in infrastructure, (and some poor MMI design...)




regards

[ATC Watcher]

Seen the situation in Tripoli today, it would seem the" LH auditors" are back in FRA and thre are reports of many civil and military pilots defecting .

On the military side, the French "consultants" refurbishing the Mirages F1 are back in France and the only 2 F1s serviceable defected to Malta.

I suspect (but no info on this) that the Airbus maintenance guys are also back home ,and that the Afriqiyah aircraft parked abroad won't be returning soon to Libya and the future of the airline is uncertain.

As to the final report , I guess it will now probably never see the light of day , burried in the old regime administration .

[Giolla]

Re: post ATC watcher

This is, right now, the main concern in Holland. Aviation authorities i.c. 'Onderzoeksraad' did not receive any information (from Libya) for months.
It is believed that the recent political developments will end this afair and the real chance that the cause of this drama will surface is close to nil.

It seems that this kind of investigations is subject to political powerplay, if it is not political it may be subject to other sorts of cover up, like the Faro diaster so clearly showed.

[76-er]

Apologies for not reading through all the 67 pages of this thread, but havn't the CVR and DFDR been sent to France for download? If the data of these recorders survived the crash relatively unscathed it should not prove too difficult to at least come up with a reliable sequence of events.

[Giolla]

The question might arise if the French investigators are willing to disclose any findings without consent of the Lybian airline.
I have no idea if the Dutch are qualified partners in the investigation. If nobody claims the finals from the examination of the equipment that has been sent to France what will be next? What I have understood is that there has been no communication for a long time between the involved parties.

[GarageYears]

The question might arise if the French investigators are willing to disclose any findings without consent of the Lybian airline.

I would have thought that the authorities in Holland might have sufficient leverage to make disclosure of the FDR/CVR possible, irrespective of the state of Afriqyah and/or the Libyan aviation authorities. In fact given the turmoil in-country this might be the exact opportune moment for that to happen.

[lomapaseo]

my experience is that if a regulatory function external to the country of operation is an obvious corrective action, than any party with knowledge of the facts will provide such recommendation.

Either way (internal to county of origin or ad-hoc elsewhere) don't expect to see this formalized in a press release.

[ATC Watcher]

The question might arise if the French investigators are willing to disclose any findings without consent of the Lybian airline

The airline has not much to say in this, the Lybian CAA has. Releasing findings such as CVRs/FDR is their call, definitively not the French BEA. The BEA will not make a report, they have no authority to do so,( neither have the Dutch by the way ) . So what will remain of the archives and the staff of the future Lybian CAA will determine if a report will be made one day or not.
But there are plenty of well educated and serious people in Lybia, so when the mess is over some might get in power and who knows.But my guess is that they will probably have a lot of more pressing things to do than to spend time and ressources on a accident that happenned in the past regime.

[Giolla]

This is fully understood. It will be a matter of the future.

[Melax]

The current (05/13/2010) Google earth imagery has the crash site before the debris removal, kind of sad to see what's left of the A-330, and make you wonder how that kid survived...
This is a link to the image, I can't seem to be able to make the insert image work ?

ImageShack® - Online Photo and Video Hosting (http://img220.imageshack.us/i/tripoliafriqyahcrash.jpg/)


http://img220.imageshack.us/i/tripoliafriqyahcrash.jpg/

[CONF iture]

Thank you Melax.

http://i65.servimg.com/u/f65/11/75/17/84/tip_0210.gif (http://www.servimg.com/image_preview.php?i=81&u=11751784)

It's about 2500 feet between what seems to be the initial impact and the wings on the far right.

[1stspotter]

Dutch NOS today has a story telling the Libyan authorities sabotaged the investigation for the cause of the crash of the Afriqayah A330.

source: NOS Nieuws - Onderzoek crash Tripoli gesaboteerd (http://nos.nl/tekst/233860-onderzoek-crash-tripoli-gesaboteerd.html)

Libyan authorities have tried from the start of the investigation into the plane crash in Tripoli to sabotage. So says an expert from the research team who has left.

According to the Libyan man wanted from the beginning to appear that the crash was caused by a heart attack in the pilot. That was already established before an autopsy was done, says the researcher. He thinks the crash was caused by sudden local fog and pilot fatigue.
At the crash in May last year were 103 deaths, including 70 Dutch.A boy of nine survived the plane crash

[XLNL]

Googe translate from Dutch.
"Libya thwarts research Tripoli crash 'LONDON - The Libyan authorities to frustrate the investigation into the plane crash in Tripoli, where 67 Dutch among others perished. Massoud Ibrahim said that aviation researcher at the NOS. He is involved in the investigation into the cause of the crash. The authorities claimed that the pilot would have a heart attack and that therefore the case has been closed. According to Ibrahim, however, no autopsy performed to find out. Similarly, the co-pilot of a heart attack to intervene. According to Ibrahim the pilot was overtired. He flew two consecutive night flights. Ibrahim is worried that the truth will never uncover long as Libyan leader Muammar Gaddafi to power. The aircraft was Muammar Gaddafi of Afriqiyah Airways, wholly owned by the State also leads the research. Afriqiyah Airways working people who would have close links with Gaddafi. Worldwide spoke to the investigator. According to journalist Hans Jaap Melissen the weather was bad and had the unit for a different job, countries that are more endowed. When French researchers took data from the black box and sent to Libya, in his opinion nothing more heard of. Contact Many attempts to make contact were unsuccessful. The contact would be complicated by the battle between insurgents and Gaddafi. Sunday morning, however, would have promised to release more information soon. The law requires the authorities to do that for May 12, then the accident in which 103 people died one year ago. A then 9-year old Dutchman survived the disaster alone.
Source (Dutch): 'Libië frustreert onderzoek Tripoli' | nu.nl/binnenland | Het laatste nieuws het eerst op nu.nl (http://www.nu.nl/binnenland/2494618/libie-frustreert-onderzoek-tripoli.html)

[lomapaseo]

Googe translate from Dutch.
"Libya thwarts research Tripoli crash 'LONDON - The Libyan authorities to frustrate the investigation into the plane crash in Tripoli, where 67 Dutch among others perished. Massoud Ibrahim said that aviation researcher at the NOS. He is involved in the investigation into the cause of the crash. The authorities claimed that the pilot would have a heart attack and that therefore the case has been closed. According to Ibrahim, however, no autopsy performed to find out. Similarly, the co-pilot of a heart attack to intervene. According to Ibrahim the pilot was overtired. He flew two consecutive night flights. Ibrahim is worried that the truth will never uncover long as Libyan leader Muammar Gaddafi to power. The aircraft was Muammar Gaddafi of Afriqiyah Airways, wholly owned by the State also leads the research. Afriqiyah Airways working people who would have close links with Gaddafi. Worldwide spoke to the investigator. According to journalist Hans Jaap Melissen the weather was bad and had the unit for a different job, countries that are more endowed. When French researchers took data from the black box and sent to Libya, in his opinion nothing more heard of. Contact Many attempts to make contact were unsuccessful. The contact would be complicated by the battle between insurgents and Gaddafi. Sunday morning, however, would have promised to release more information soon. The law requires the authorities to do that for May 12, then the accident in which 103 people died one year ago. A then 9-year old Dutchman survived the disaster alone.
Source (Dutch): 'Libië frustreert onderzoek Tripoli' | nu.nl/binnenland | Het laatste nieuws het eerst op nu.nl (http://www.nu.nl/binnenland/2494618/libie-frustreert-onderzoek-tripoli.html)



I guess there are newspapers, magazines and Google translations, but so far no confirmation that this is actually sourced to an investigating body under ICAO.

[Super VC-10]

Maybe not, but the Nederlandse Omroep Stichting is as good a source as Voice of America, for example.

[Wsx]

An article in a Dutch magazine:

(improved Google translation)


By Harald Doornbos | 12 Mei 2011 - 11:57

BENGHAZI - Afriqiyah Airways flight 771 has crashed because of a catastrophic combination of six cases of gross negligence by Libya's crew, the control tower and the airline itself. So says Naser Amer, pilot and former flight safety officer of Afriqiyah Airways, in an exclusive interview with correspondent Harald Doornbos for HP/De Tijd. From the eastern Libyan city of Benghazi for the first time Amer brings clarity about the disaster in which exactly one year ago, 103 people died, including 67 Dutch.

Amer indicates an accumulation of failures, including six crucial. First, not the experienced captain, but a young first officer was at the controls of the disaster plane which was en route from Johannesburg to Tripoli. This first officer made a crucial error just before the crash by pushing the nose down instead of up. When this happened the captain did not intervene to prevent the crash. Earlier, the control tower in Tripoli sent the plane to the wrong runway. To make matters worse, there was two weeks before the crash, on a flight from London to Tripoli, a near-accident with exactly the same plane and same crew. This creates suspicions that something was wrong with the airplane. Against all internal rules of Afriqiyah this near-accident was not reported by the captain. Computer data of this near-collision reached Naser Amer far too late. Not within three days, as it should, but only after thirteen days - just half a day before the accident that killed the Dutchmen. In any event, too late for Amer to keep the captain and first officer of the disaster plane on the ground.

Naser Amer, who graduated from Oxford University in 1977, was until February this year one of the executives within Afriqiyah. He worked for thirty years as a pilot and instructor in Switzerland and Libya, he got training at Schiphol airport among other places. Amer was not part of the official inquiry into the disaster, but as a pilot and flight safety officer of Afriqiyah, he nevertheless was closely involved in the investigation. For example, with support of the Slovenian airline Adria he made an accurate simulation of the flight path of the disaster flight. Also, Amer was kept informed by Afriqiyah colleagues of the investigation. Amer reported these findings directly to the Director of Afriqiyah. As flight safety officer, he had the power to "suspend or investigate any pilot of Afriqiyah".
Amer fled on February 19, two days after the outbreak of a popular uprising in Libya, from Tripoli to Switzerland, where he has a house. Until that time he was a pilot and flight safety officer. From Switzerland, he traveled to Benghazi in eastern Libya. Previously he was forced to fly pro-Gaddafi-mercenaries of the city Sirte to his birthplace Benghazi. "I did not want to participate in Gaddafi's terror," said Amer. "So I fled". "I suppose I'm fired now".

"It was a cloudy day with lots of low clouds," recalls Naser Amer the day of the fatal accident. "The plane was told to land on runway 09 by the control tower". That is not good compared with runway 27, where you can land on autopilot. "Runway 09 only has the possibility of a non-precision landing with the inferior VOR-system."
Why the control tower did not allow the pilot of flight 771 to land on the safer runway 27, is according to Amer part of what he calls "the Libyan mentality. "You can not as a pilot go in debate with the tower," he says. "They give you an assignment and you must adhere to it. The tower prefers runway 09 because it is easier for them. "So they do not have to look at the sun. "
What would have happened if flight 771 had been sent to runway 27? "There would have been no disaster." says Amer decidedly. "Then the plane would have landed safely."
When the landing was then attempted to the more primitive runway 09 it became clear that the airplane could not land because of low clouds. Upon this the pilot decided to do a 'go-around'. This means that the landing is abandoned and the plane climbs, flies around and attempts a new landing. But instead of pulling the plane up, the pilot pushed the plane down, making it hit the ground and crash.

The main points of Naser Ames' story are confirmed by a second pilot in Libya, who wishes to remain anonymous but whose name and credentials are known to the author. This pilot, also a Libyan, was with his plane at the runway waiting for permission for departure to an oil field in central Libya when Flight 771 crashed. "I saw a cloud of smoke and then I immediately contacted the control tower," he recalls the time of the accident on May 12, 2010. "I do not believe that the tower had already realized that there had been an accident. I also did not know exactly, because it was a big cloud of smoke. But I feared already in the first seconds the worst."
According to this pilot, who was less involved in the investigation into the disaster than Naser Amer, choosing the wrong runway was crucial. "The control tower has made a big mistake by letting the aircraft land on Runway 09, and not on 27," he says. "I have no idea why they are so insistent on it."-
"The weather has only played a minor role during the disaster," says the anonymous pilot. "As the plane just before the accident flight had just landed normally at Tripoli airport. They did not do a 'go-around'. They saw a hole in the clouds and just landed safely. Then came flight 771, which made a go-around - but that went wrong. "

Back to pilot Naser Amer. Until now, everyone assumes that the pilot of the plane was experienced captain Yusuf El-Saadi. This is not true according to Naser Amer. "It was the first officer Tariq [Mousa, ed] in control at the time of the crash." Why not the captain who had more experience? "We do not know," said Amer.
According to Amer captain El-Saadi, based on data from the voice recorder, gave control to first officer Tariq one hour after leaving Johannesburg. Subsequently, captain El-Saadi left the cockpit and he slept a few hours. This is a normal procedure, because with a captain sleeping outside the cockpit there still remain two co-pilots: first officer Tareq Mousa and second officer Nazem El-Mabruk.
According to the voice recorder sixty minutes before landing captain El-Saadi returned to the cockpit, but the controls remained until the last moment in the hands of first officer Tariq Mousa.
"Instead of the go-around and back upward, the plane dived down and crashed," says Amer. "Whether that was a mistake of the first officer or perhaps a fault of the aircraft, we do not know. For even the French - investigating the plane - have not finished their investigation. "

As the plane just before the crash flew down instead of up, captain El-Saadi, sitting next to first officer Mousa, still could have intervened quickly and take control. But somehow the captain did nothing. According to Amer, on the CVR the voice of the second officer is audible shouting in panic the half sentence, "What's wrong with the c..."
Further analysis of the CVR of this particular phrase has led researchers to believe that the second officer would say: "What is wrong with the captain?"
"It could be that captain El-Saadi was so shocked by the steering error that he could not intervene," Amer guesses. "It could also be that something was wrong with the captain. That he had a heart attack or was unconscious. But we are not sure. "
Amer knows the killed crew personally. "Captain El-Saadi was a good friend of mine. We have studied together at Oxford. "

It is shocking that the disaster totally could have been avoided if Afriqiyah two weeks earlier had complied with its own rules better. On April 28, 2010 namely there is an Afriqiyah Airways flight from London to Tripoli. This is exactly the same plane that crashes fourteen days later. Captain El-Saadi and co-pilot Mousa are present. As in the May 12 disaster flight on April 28 there are low clouds in Tripoli.
"Also during this flight the pilot was first officer Tariq," says Amer. "Captain El-Saadi sat beside him." Because of the clouds the pilot wanted to make a go-around, which is a standard action for pilots. But instead of pulling up the nose of the plane went right down. "Just before the plane hit the ground, captain El-Saadi could luckily intervene and correct first officer Tariq in time," says Amer. "I always say that the crash of the plane from Johannesburg should have happened two weeks earlier, with the plane from London."
Problem for flight safety officer Amer was that captain El-Saadi and first pilot Tariq Mousa concealed the very serious incident on the London flight.
"Of course they should have reported this incident to me, but they have not done so," says Amer. "So I was not aware of this near-accident. If I had known I would have suspended them and have an investigation carried out. Then two weeks later, the disaster of the Johannesburg flight would never have taken place. "

Because Afriqiya has a second recording system, the non-reporting of the near-crash during the London flight would be discovered otherwise. "We check all data of all our flights through a system called Airface," says Amer. "This is how I as flight safety officer still have found that almost an accident had occurred during the Tripoli-London flight on April 28. But the company that supplies us with this data is messy and slow. Officially they are supposed to give us the data of a flight three days after the flight. But there was a problem to get the data from the airport to our office. These guys are not organized. The data of the London-Tripoli flight reached our office only until thirteen days later, at the end of the afternoon. The data was loaded in our computers on may 11, but by then we had already left our office. The next day we were going to analyse the London-Tripoli-flight, but before we came to it, the disaster took place with the flight from Johannesburg. "

The reason Naser Amer now breaks the silence about the true nature of the disaster, is because he wants the Netherlands to know the truth. "I can speak freely because I am no longer in the area of Gaddafi," he says. "Gaddafi ruled Libya not as a country, but as his own farm. There was corruption, people were disorganized and did not take their responsibility. Ultimately it goes wrong and that will cost many human lives."
The anonymous pilot says: "There are many mistakes. The tower made the plane land on the wrong runway and the go-around went inexplicably wrong. Here people have dropped the ball."
Naser Amer says he regrets what happened. "Terrible, all those people who have died - most of them were Dutch," he says. "Hereby I condole all survivors. It is a tragedy for the Libyans, the South Africans and especially the Dutch people."

link (with picture):
Een jaar na de ramp: 'Er zijn veel fouten gemaakt' - HP/De Tijd (http://www.hpdetijd.nl/2011-05-12/een-jaar-na-de-vliegramp)

(http://translate.google.com/translate?js=n&prev=_t&hl=en&ie=UTF-8&layout=2&eotf=1&sl=nl&tl=en&u=http%3A%2F%2Fwww.hpdetijd.nl%2F2011-05-12%2Feen-jaar-na-de-vliegramp)

[aterpster]

I guess we have the revolt/NATO action to thank for this fine gentleman providing what I am sure is the authoritative report on the accident. Had stability remained I doubt he would have been able to provide his report.

[PLovett]

But instead of pulling the plane up, the pilot pushed the plane down, making it hit the ground and crash.

I wonder if somatogravic effect has some part in this crash. I know it wasn't night but the aircraft may have been in cloud.

[GlueBall]

"The control tower has made a big mistake by letting the aircraft land on Runway 09, and not on 27," he says. "I have no idea why they are so insistent on it."-

...It's hard to comprehend how a visual or non precision approach to Rwy-9, would be entertained as a probable cause for the crash. Having the sun in your face is a recurring event at airports all over the world :rolleyes:

[scanhorse]

I wonder if somatogravic effect has some part in this crash.

I find this old thread in trying to understand this "effect"
and googled for other , but find no good
and all the links in old thread are "ded!

http://www.pprune.org/tech-log/9199-somatogravic-illusion.html

somebody have a good link of explaining the fenomen
Maybe we can update the good old link :)

Ulf

[lederhosen]

It all sounds quite possible. A trail of small factors leading up to the big hole. The tower favour the runway that suits them so they do not have to squint into the sun. The captain is feeling off colour, spends most of the flight in the cabin and lets the tired copilot do the non precision approach into the sun with low clouds making the runway hard to see. When the correct decision to go around occurs, the captain takes over, has a heart attack and the rest is history. Sure the last part is conjecture, but it is a hypothesis I would certainly explore. At the very least even if he did not take over, it could have distracted the copilot. Reminds me a bit of the Staines Trident where the captain was also conjectured to have had a heart attack. The only bit that I doubt, is that Captain Amer graduated from Oxford University, though he most probably trained at Oxford Aviation.

[RetiredF4]

scanhorse
somatogravic effect
Quote:
I wonder if somatogravic effect has some part in this crash.
I find this old thread in trying to understand this "effect"
and googled for other , but find no good
and all the links in old thread are "ded!

somatogravic illusion

somebody have a good link of explaining the fenomen
Maybe we can update the good old link

Ulf

Just start reading on page 47, it has been discussed in great detail.

Some reference here (http://www.pilotfriend.com/aeromed/medical/false_climb.htm)

franzl

[ehwatezedoing]

Having the sun in your face is a recurring event at airports all over the world :rolleyes:
I agree but the argument of having to land the sun in my face so "they" don't have it in their face kind of p!sses me off though.. :=

And to go back with the topic, apparently "they" weren't even looking out (away from the sun) since it's a crew waiting for departure that noticed them of the accident.

[scanhorse]

Just start reading on page 47, it has been discussed in great detail.

Some reference here

franzl

Big thank you Thread is tooo Big :)

Ulf
I update old thread with new info
(but that was a closed thread :( )

[fantom]

You may be aware of the fact that...

The FDR will reveal the movements of both side-sticks - that is: who was imputting control at the time. If the captain had tried to take over/if the FO flew it into the ground/if the captain had incapacitation and pushed the stick forward - these things are revealed.

[lederhosen]

The flight safety officer's version might be reasonably expected to mention input from the captain's sidestick had it been recorded. One possibility is a more insidious incapacitation, that might also partially explain why the crew were distracted enough to descend well below minimum before trying to initiate the go around. The implication of the serious incident, which occured on a flight shortly before, is that this was a crew in any case not at the top of their game.

[captplaystation]

Given the events in Libya, who knows ? but does anyone know if an agency (somewhere) are progressing the investigation ? Airbus ? or the Dutch (given how many of their nationals were counted amongst the victims)
I realise that whatever agency in Libya was tasked with investigating this may not even exist anymore (physically or metaphorically :hmm: ) but just wondered if somebody "offshore" was running with it.
As a confirmed Scarebus -sceptic, I would be disillusioned if this one is just swept under the carpet under the catchall conclusion of "crew machine interaction/crew cock-up" as so often happens when these devices go wrong, or to pacify the "lovers" are. . . wrongly operated.

[Dani]

and I wonder that the public still doesn't know the cause of the accident.

FO pressed take-over button (i.e. autopilot off) instead of push-to-talk switch for the radio, captain didn't realize that autopilot isn't flying, never took over airplane, crashed into the ground.

This is from very reliable sources.

[Lonewolf_50]

Ouch! :eek:

If true, that would be, sadly, not the first ever "knobology/switchology" crash, and likely not the last. :uhoh:

[Hotel Tango]

:confused: But there is a distinct aural warning when the AP is disconnected!

[RegDep]

15 months ago….. http://www.pprune.org/rumours-news/414936-afriqiyah-airbus-330-crash-61.html#post5770568

[Lonewolf_50]

Hotel Tango: depending upon task loading, would that aural warning trigger a response on short final? Hopefully, yes.

About aural warnings, like the stall warning of AF447 going off for a while: sometimes the sound doesn't penetrate into the aware part of the pilot's attention.

[Lyman]

I think a/p selected off is "Cavalry Charge" and "Master Caution". Unless that is auto drop only.

[Dani]

yeah, cavalry and Level 3 warning.

But it was more complicated: The guy (as they say) continued talking on the radio and kept on pressing the AP off button. There is a Priority-light plus Voice warning if you press that button. But if you keep on pressing you lock out the other side stick. Until the other presses it too. But obviously never did...

[Swiss Cheese]

The Libyans were not being overly helpful to the foreign accredited investigators before the revolution, and nothing has progressed since January.

Families are now petitioning ICAO to do something useful, which might be getting the BEA to take over charge of the investigation (since they are experts on A330 problems these days)

watch this space

[Giolla]

No one knows what to do here. A Dutch news-bulletin (Nu.nl) wrote that it is also the fault of the particular (Dutch) governmental institutions who are quite unwilling to show some action.

On the other hand, what can one do under those chaotic circumstances where the investigating body is destroyed in the battlescene.

One should consider that traveling Africa is subject to a certain degree of extra risk. Men and machine are less predictable and sudden mishaps are a continuous source of worry.

[Dani]

and I'm sure the new Libyan government doesn't want to do anything that has ties to the former dictatorship. They said very clearly that they don't reconsider any claims before the revolution, be it legal cases (against Bulgarians, Swiss), be it the Pan Am bomber, be it a lawsuit against Ghadaffi (they just killed him). This is year zero after the revolution, from now on they count from new and don't look back.

[wingview]

It's pretty simple. If it was a technical failure we would have known this for ages. The fact that we still don't know says it all!

[aterpster]

Dani:

and I'm sure the new Libyan government doesn't want to do anything that has ties to the former dictatorship. They said very clearly that they don't reconsider any claims before the revolution, be it legal cases (against Bulgarians, Swiss), be it the Pan Am bomber, be it a lawsuit against Ghadaffi (they just killed him). This is year zero after the revolution, from now on they count from new and don't look back.

This accident and its attendant politics is as good of a lesson as any why third world airlines should be avoided.

[Lonewolf_50]

What aterpster said.

[Giolla]

I would accept Amer' s wording as being the most appropriate explanation for this unnecessary drama.

Airbus (and other manufaturers) should have the self-discipline not to sell those overcomplicated pieces of technology to incapable (B-class or lower) operators. That should be a number 1 target. And certainly not into African airspace, where well executed maintenance (not in this case) is as seldom as gold on the streets of Cairo.

[BOAC]

This accident and its attendant politics is as good of a lesson as any why third world airlines should be avoided. - placing Air France where?

[Alexander de Meerkat]

It is fairly self-evident this accident arose because of pilot error in that a 100% serviceable A330 operated well within its design capability and approved weather limits crashed during the incorrect execution of a go-around.

[Dav66id77]

Libyan Civil Aviation Authorities have been warned officially by EASA on falling below all acceptable standards.
This includes safety oversight on its operators (a.o. Afriqiyah) and their own organization.

Most likely the Libyans will now blame non Libyans, preferably Westerners, for this disaster.

[Mister Geezer]

The Libyans will be very reluctant in moving this investigation forward since they don't want to 'crap on their own doorstep'! Having worked as crew for a Libyan operator in the past, I know that suffering a 'loss of face' in that part of the world is nothing short of humiliating. Afriqiyah had and will perhaps now have even more ambitious expansion plans. Tarnishing the image of the national carrier will not be something that the Libyans will be in a hurry to do.

[aterpster]

Mister Geezer:

The Libyans will be very reluctant in moving this investigation forward since they don't want to 'crap on their own doorstep'! Having worked as crew for a Libyan operator in the past, I know that suffering a 'loss of face' in that part of the world is nothing short of humiliating. Afriqiyah had and will perhaps now have even more ambitious expansion plans. Tarnishing the image of the national carrier will not be something that the Libyans will be in a hurry to do.

Huh? They have already done that with the speed of light. The new government is really screwed up if they believe they can leave that terrible crash unexplained.

[Mister Geezer]

Whilst Afriqiyah is looked upon in varying degrees of favour by the outside world, no Libyan connected to the government nor the investigation has publicly denounced the company. Nor will they probably even dare to do so either and it has nothing to do with free speech or democracy. Libyans are probably the most hospitable group of people I have ever worked with but they are also some of the most reserved too.

It is going to take Libya a long time to create a credible and robust government to lead the country forward. Investigating an accident which involves their national carrier will be far down their list of priorities. As each month passes, it becomes less likely that any credible findings will ever be published.

That statement maybe rather controversial and perhaps difficult to comprehend but there are not many countries that are in the process of rebuilding themselves from scratch after just over four decades under ruthless dictatorship. Libya is unique in many ways.

[aterpster]

BOAC:

- placing Air France where?

As first world as the UK or the US.

[Nubboy]

Thread drift prhaps, but I'm with BOAC on this question.
Used to work in the oil industry for the French arm of a huge multinational and the level of corporate arrogance had to be seen to be believed. This I think was a reflection of their national culture.

[golfyankeesierra]

Always funny when the Brits start accusing the French of arrogance... (pot, kettle..) :roll eyes:

Anyway, they have loads of data + CVR. While the official report is farther away then ever, a lot of French, US, and Dutch investigators must have a very good idea of what happened, but the only thing in the rumour-circuit was the F/O supposedly mixing up the x-mit button with the a/p disconnect button (and which was probably not more than that, a rumour).
Really no news??

[PAXboy]

GiollaAirbus (and other manufaturers) should have the self-discipline not to sell those overcomplicated pieces of technology to incapable (B-class or lower) operators. That should be a number 1 target.That is, if I might venture, a slightly unrealistic view of a commercial company? In the same way that Holland might not sell water damming equipment and channeling expertise to countries that might then severly alter the balance of water flows in their country and cause unexpected flooding?

[Dani]

Airbus is in fact actually doing that (in contradiction to a certain B-company, that's why you see mainly 737 in low developped countries). But oil rich countries used to have a quite good safety record so far.

[johnnyringo42]

BOAC, I love your response. some people just don't think when they comment.

[Giolla]

@ Paxboy

The volumes of investment required to operate and maintain a single up-to-date passenger A/C to FAA standards is far beyond the assets of the majority of B class (African) operators.

I would be interested to know if any payment has been effectuated as per yet to the estates of the deceased passengers.

[golfyankeesierra]

As I understand it, it was Khadaffi's personal intend to make Afriqiyah the nr 1 airline of Africa. So money was probably no issue. (Kind of Emirates' remake in another desert)

How they will fare under new circumstances remains something else.

[Giolla]

I do not point at Afriqiyah in this respect. The A/C was close to new and most probably 99% to factory specs.
Evaluating the present political situation in Libya, the crash might never been explained for. Unless some miracle will happen.

[decurion]

The Dutch Minister of Foreign Affairs Mr. Rosenthal has been in Tripoli last Sunday. He spoke to Mustafa Abdul Jali about the accident investigation. The Minister stated that the investigation was completed for 70% (most likely the work done by the BEA). He hoped that the investigation would be finished within 6 months. However, no guarantees could be given.


NOS Nieuws - Rosenthal op bezoek in Tripoli (http://nos.nl/artikel/313047-rosenthal-op-bezoek-in-tripoli.html)

[DutchSpotter]

Finally news on the investigation on the cause of the Airbus A330 crash.
Report ready before the end of summer.

Google translation of 'Onderzoek ramp Tripoli snel klaar' - Binnenland | Het laatste nieuws uit Nederland leest u op Telegraaf.nl [binnenland] (http://www.telegraaf.nl/binnenland/12666764/___Onderzoek_Tripoli_snel_klaar___.html)


TRIPOLI - It will not be long until the investigation into the crash in Tripoli has been completed. That is the principal investigator Libyan Neji Dhaou against the NOS said. The revolt against Gaddafi's regime led to the earlier delay, but Dhao expected within weeks the draft report for comments around to send.

In May 2010 came to 103 people in the crash, including 70 Dutch. A 9-year-old boy from Tilburg survived as the only passenger plane crash.

The official declaration of the Kaddafiregime after the disaster was that the pilot had received a cardiac arrest. According to other sources of the two pilots had enough rest and he failed during landing in rough weather.

[1stspotter]

Finally news on the investigation of the Afriqiyah Airbus A330 crash at Tripoli.
The draft investigation report is ready and sent to the Dutch Safety Investigation authorities.
After experts will comment on the report, the final report will be ready begin of 2013.


translation of news which appeared today
Google Vertalen (http://translate.google.com/translate?sl=auto&tl=en&js=n&prev=_t&hl=nl&ie=UTF-8&layout=2&eotf=1&u=http%3A%2F%2Fnos.nl%2Fartikel%2F438371-onderzoek-vliegramp-libie-afgerond.html&act=url)

[1stspotter]

Today finally some news on the release of a final report on the investigation of the Afriqiyah A330 crash.

The public release of the report has been postponed for a few months.

reported at
http://www.luchtvaartnieuws.nl/nl-NL/Article.cms/Airlines/Voorlopig_nog_geen_rapport_vliegramp_Tripoli?utm_source=twit terfeed&utm_medium=twitter&utm_campaign=Luchtvaartnieuws.nl

google translation:
THE HAGUE - The investigation into the plane crash in the Libyan capital Tripoli in 2010, which killed seventy Dutch, will be released in the public in a few months. Minister Frans Timmermans of Foreign Affairs on Monday informed the Lower House. In November, the draft version of the report concluded.

This version has been sent to several authorities for comment, including the Dutch Safety Board. Then the expectation of the Research Council is the final report early this year would be made public. The comments of the various agencies are now processed by the Libyan authorities. Only when they have completed, the final report comes out.

The research was greatly delayed by the revolution in the North African country that ended the regime of Muammar Gaddafi. When the disaster on 12 May with an Airbus A330-200 of airline Afriqiyah Airways 103 people were killed. Only a nine year old Dutch boy survived the disaster.

[Giolla]

Is it common practise to issue a draft investigation to a 3rd party, not officially involved in the investigation procedures?
In this case the Transport & Veiligheidsraad of the Dutch Government.

Secondly, my earlier question was about an eventual (provisional) financial compensation to the estates of the Dutch victims. The press did not publish substantial information about this subject.

The Dutch daily, "Telegraaf" lately published a random article about the diaster but did not came with explicit information on top of what we know, or suspect, already.

What is the basic text of this "preliminary" or draft report? Is it in French or English? I do read both languages.

[ATC Watcher]

Yes it is normal common practice to Send preliminary drafts reports to third involved parties for comment before publication . Nothing wrong here . I doubt very much , seing the parties invilved , that the report will be in other than English , definitively not in French I would say.

[Swiss Cheese]

The draft report will be in English (as per ICAO Standards and Chicago Convention 1944, Annex 13). Ditto the final report. No public access to the draft, but Airbus and the Libyan Government will have their say over the Draft version. The families of the deceased passengers and crew will not have any say in that process.

As for compensation, there is a strict two year time limit from the date of the accident to bring claims against the airline. (Obviously the airline is insured, actually at Lloyds of London.) If the Accident report reveals an Airbus problem, then claims are still valid against them in certain countries.

This highlights the problems that families of deceased passengers and crew face when accident reports are slow to be published. The last time this happened was the Kenya Airways KQ507 at Cameroon in May 2007, when it took over 3 years for the accident report to be published.

Please PM me if you need specific advice about this accident as I am representing many of the families.

[Giolla]

I am an ex airport manager and used to fly single prop light aircraft. I am still interested in airline business and related subjects.

The Afriqyah-case interest me because of the fact that ultra-modern aircraft flies in an environment where technical / instrumental support from modern ILS sytems is missing and/or not working.

It looks like the Airbus is too sophisticated for use in African (conflicting) conditions. Unless flown by those who are die hard veterans.

I must say that I am still surprised that the Lybians could conclude a final issue in this bizarre accident.

[1stspotter]

The report on the crash in Tripoli will be made public very soon. Maybe even this week although an exact date has not been announced.

At February 27 the Dutch Onderzoeksraad voor Veiligheid issued a press release. See the Dutch version here.
Publicatie onderzoek vliegramp Tripoli verwacht - Pers - De Onderzoeksraad voor veiligheid (http://www.onderzoeksraad.nl/index.php/pers/publicatie-onderzoek-vliegramp-tripoli-verwacht/)

Will keep you posted as soon as the report is available.

[76-er]

Dutch Teletext now reporting the official presentation will be tomorrow.

[1stspotter]

Investigators have told Dutch NOS that the cause of the Afriqiyah Airbus A330 crash was due to human error and technical failure.

The report of the cause will be presented at February 28.

Source:
NOS Teletekst (http://nos.nl/teletekst/#133_01)

[fantom]

'Technical failure'?

I don't believe it for one second.

[RoyHudd]

For "technical failure" read "another Middle-East Cover-Up".

Shades of the Egyptair pilot in-flight suicide denial. These people just cannot bear to admit their mistakes. Ever. Which is why I personally would never fly with such airlines.

[1stspotter]

Lets wait and read the report outselves when it becomes available before jumping to conclusions.

The report does says HUMAN Error is one of the causes! And technical failure which could be navigational aid (read about the NDB which was more unserviceable than operational) or the aircraft.

In the past (Khadafi time) the government said the pilot got a heartattack. This is not listed as a cause anymore in the official report.

[space pig]

"It looks like the Airbus is too sophisticated for use in African (conflicting) conditions. Unless flown by those who are die hard veterans."

Utter nonsense.The aircraft is not the factor is this case, but non compliance with instrument procedures and lack of flying skills.

having flown many years in Lybia myself as expat captain, we were often politically forced to fly with local lybian co- pilots, who all showed, despite many years of flightexperience similar caracteristics: Poor aircraft knowledge and flying skills, low compliance to instrument procedures, VFR orientated .

All occasions when we hit the minima and negative contact, they would continue visual "trying to find the runway" instead of going around, often following a road or similar landmarks.

Almost certain this is what happened here. Having flown the NBD to RWY 09 a lot there is nothing inherently dangerous about it and the airbus would have certainly assisted them with a GPS overlay to make it even more accurate, especially if the accuracy of the NBD would have let them down.

What contributes to the crews lack of airmanship is that they did not ask for 27 with an ILS-the wind was calm- (the sun would not be glaring in their face and lower minima), but most of all that fog-morning fog in Tripoli is -and any local pilot can or should tell you that-allways is a very shorterm issue, and will clear in 20-30 min, often less and a short hold would have solved it.

Instead the crew choose to shortcut and take RWY 09 to save time, hoping to get to the minima visually albeit against the odds and thereafter decided to continue visually, "not to lose face", even when they did not have the RWY in sight, and killing all those innocent people in the process...

[1stspotter]

Today the Libyan authorities published the final report on the Airbus A330 crash. It can be downloaded here
مصلØ*Ø© الطيران المدني - Home (http://caa.ly/en/)

Big human errors are the main cause.

The aircraft's approach was too low without proper sight of the ground. Pilots did not work together properly, were tired and distracted by busy radio communications. Also the weather forecast was not correct.
Also the co-pilot pulled nose up while the captain pulled nose down!

Below is a small part of the complete report which has 4 PDF files.

Probable Cause
A final approach carried out in common managed guidance mode should have relieved the crew of their tasks. The limited coordination and cooperation between the two crew members, especially the change into vertical selected guidance mode by the PF, probably led to a lack of a common action plan.
The lack of feedback from the 28 April 2010 flight, flown by the same crew on the same aircraft, did not allow them to anticipate the potential risks associated with managing non-precision approaches.
The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
During the go-around, the crew was surprised not to acquire visual references. On one hand the crew feared exceeding the aircraft’s speed limits in relation to its configuration, and on the other hand they were feeling the effects of somatogravic illusion due to the aircraft acceleration. This probably explains the aircraft handling inputs, mainly nose-down inputs,
applied during the go-around. These inputs were not consistent with what is expected in this flight phase. The degraded CRM did not make it possible for either crew member to identify and recover from the situation before the collision with the ground, even when the TAWS warnings were activated close to the ground.

Based on elements from the investigation, the accident resulted from:
-The lack of common action plan during the approach and a final approach
continued below the MDA, without ground visual reference acquired.
-The inappropriate application of flight control inputs during a go- around and on the
activation of TAWS warnings,
- The lack of monitoring and controlling of the flight path.
These events can be explained by the following factors:
- Limited CRM on approach that degraded during the missed approach. This
degradation was probably amplified by numerous radio-communications during the final approach and the crew’s state of fatigue,
-Aircraft control inputs typical in the occurrence of somatogravic perceptual illusions,
- Inappropriate systematic analysis of flight data and feedback mechanism within the AFRIQIYAH Airways.
- Non adherence to the company operation manual, SOP and standard terminology.
In addition, the investigation committee found the following as contributing factors to the accident:
-Weather available to the crew did not reflect the actual weather situation in the final approach segment at Tripoli International Airport.
-In adequacy of training received by the crew.
-Occupancy of tower frequency by both air and ground movements control.

[aterpster]

I downloaded all four parts, all of which had fatal errors when I attempted to open them.

[Capn Bloggs]

You must be Amercian, Terps. I only downloaded the first part and it opened OK. Hit the ground doing 260KIAS at -4400ft/min sink, captain on the controls. :(

[Clandestino]

If you are downloading the report, don't bother downloading part 3, it's just pathological info on all the victims in Arabic.

[ATC Watcher]

Conflicting stick inputs again. confusion PNF-PF, lack of CRM , no calls of who has control before taking over.. reminds me of another A330 crash report..:(

[Alexander de Meerkat]

If ever there was a warning as to the importance of putting correctly constituted crews with the appropriate competence, currency, experience and training in the cockpit of a commercial airliner, this was it. If you select your crews on the basis of who knows Col Gaddafi, his wife, her tennis partners or their beach mates then this is what happens. Flying in marginal conditions is tricky enough for the most competent - why make it more difficult by placing numpties in the cockpit who are partially trained and regulated. Sadly, it will not be the last time we read of crashes involving crazy countries and their poorly-selected and half-trained pilots.

[fantom]

260KIAS at -4400ft/min sink

Wow. That is not easy to achieve on a go-around...

[Clandestino]

Sadly, it will not be the last time we read of crashes involving crazy countries and their poorly-selected and half-trained pilots.So, are sane countries and their well-selected and fully-trained pilots are immune to such calamities? Afriqiyah captain pushed when receiving GPWS alert, what prevents first world pilot from performing similar feat, e.g. pulling the stick when stall warning goes off?

Sadly, there is nothing new to learn from this accident. It's just a re-hash of previous badly managed and flown flights, that received the final blow from simple and well known illusion.

Even worse, opportunity of re-learning some old lessons that got forgotten will be missed by those ascribing the accident just to awful safety culture in Libya, assuming such-a-thing-can-not-happen-to-oh-so-enlightened-us. Upside of such an attitude is, unlike AF447, this thread won't get much attention from conspiracy theorists trying to deflect the blame from crew to aeroplane, but it's such a terribly small one.

[PJ2]

For those having trouble downloading the four sections of the report, (including us Canadians, Capn Bloggs ;)), just right-click on the link and select "Save Link As...". Save them and use the usual double-click to open them.

[lederhosen]

One shocking aspect is that this same crew flying the same aircraft and on the same approach exactly two weeks before, completely messed it up in a very similar way (descending too early and triggering a terrain warning). The main difference was that they did not crash, but they did bust all sorts of limits on the very poorly flown go around. Based on those two flights the amazing thing is that in their combined twenty thousand hours they did not kill themselves earlier. This report should be required reading for all airline executives who think pilots should be sourced and trained as cheaply as possible.

[PJ2]

"This report should be required reading for all airline executives who think pilots should be sourced and trained as cheaply as possible"

Airline managements generally believe accidents won't happen to them. My bet is not one senior manager nor one executive of any major carrier actually reads an accident report. It always happens to the other airline.

However, this report should be required reading for airline managements who don't/won't implement flight data analysis & monitoring programs.

Had the previous unstable approach been picked up in the data and the crew contacted, (due to the serious nature of the events including EGPWS warnings), perhaps this accident would not have occurred. As it is, Afriqiyah's FDA Program was not operational and the previous approach by this crew was not examined.

[atakacs]

As the aircraft lost height the terrain-awareness system issued a succession of sink and ground-proximity warnings. But the captain responded with a "sharp" nose-down input, says the inquiry, adding that he might have been subject to somatogravic illusion or was similarly focused on the A330's speed.

He then took control of the aircraft, without warning, via the sidestick priority button and maintained the nose-down input, while the first officer was simultaneously - and in vain - pulling back on his own sidestick.

Scary stuff. I can't fathom why a pilot would respond to GPW wit a sharp nose done input... ?!

[Pali]

We would need to contact the guys and ask them what they thought...

But then we need to enhance the hearing to invite also pilots from Colgan Air, AF447, etc.

[Right Way Up]

What is amazing is that having problems flying the approach a few weeks before, they went for the abbreviated briefing!

[Capn Bloggs]

I can't fathom why a pilot would respond to GPW wit a sharp nose done input... ?!
Read up on somatogravic illusion phenomena, Appendix 6 in part of the report.

[jcjeant]

This report should be required reading for all airline executives who think pilots should be sourced and trained as cheaply as possible.
Not only airline executives ....
I think it would also be useful for all potential passengers to also read this kind of report
It certainly will not appeal to companies .. and introductory sessions for passengers to overcome their fear of flying .. will certainly be sought .. :ooh:

[RoyHudd]

A lot of confusion here, coming from folks who clearly do not fly for a living.

Good pilots always read accident reports, which are always circulated and studied by Safety Departments of good airlines.

Passengers will not benefit from reading such reports, unless they are dumbed down for layman comprehension. They will only misinterpret much technical information, having not been trained as pilots.

You can't pull down and pull up! That is possibly the very first lesson a student pilot learns. (Effects of Controls)

As an aside, like space pig I flew for a while in Libya on A320's alongside Libyan Captains and FO's. Most of them were appalling, and very quickly were taken off the line. And many more were chopped in sim training. They simply lacked the technical abilities to understand and consequently fly these advanced automated aircraft. Their CRM was non-existent. The Libyan Cabin Crew (all male) were equally dodgy, but more pleasant people.

[tcas69]

Spoke to the TRE who failed exactly this crew in the sim only to be overridden by his local counterpart. Met him shortly after the accident.
One of the reasons he quit.

[Artic flyer]

I can't fathom why a pilot would respond to GPW wit a sharp nose done input... ?!
Read up on somatogravic illusion phenomena, Appendix 6 in part of the report.

A make a slight different approach here , eventually first officer suffered from somatogravic illusion but that was not determinant. The really problem here seems to be a wrong reaction from captain to “sink” aural alert from avionics.


I guess he misunderstood the situation, and thought that they were stalling, sow he imputed an aggressive nose down command to recover from that illusory stalling!


Note that this is another CFIT, where bad communication between pilots, bad instrument skills, and overall tiredness should have played an important role.


I also think that a good envelope protection in a airplane should prevent things like this !!! The speed was ok to maintain airplane flying the airport was relatively far, so i guess that a well done envelope should override captain’s disastrous inputs !

[CATIIIBnoDH]

Here you can read the response of the Dutch Safety Board on the Tripoli crash.
It's another sad example how things go wrong in an aviation world were these things still occur, when will we ever learn...... Ofcourse a lot of responses will appear in the next weeks and many will confess that this will never happen to them, however it happened again. When will we ever learn.....

http://www.onderzoeksraad.nl/docs/rapporten/2012-11-29_Brief_Civil_Aviation_Authority_of_Libya_inzake_Tripoli_Ov V_1250152.pdf

[Alexander de Meerkat]

Clandestino - I would draw your attention to the informed comments of RoyHudd who has genuine first hand experience of the situation. Every nation on Earth has its fair share of imbeciles who should never, ever darken the door of a complex commercial aircraft like an Airbus. The difference between the western and non-western world is that, generally speaking, the western world has selection processes in place to ensure the pilots selected to fly these machines, particularly the captains, are fundamentally competent to do so. Sure, there will be notable exceptions, but they are few and far between.

I spoke to a European FO who did a contract at Afriqiyah, and let me tell you his observations. He said that it was an accident waiting to happen and everyone knew it. Basically, they re-equipped with Airbuses but had no Libyans to fly them. This was due to years of sanctions and the fact that some Libyan pilots had not flown for more than ten years. Not to worry, they could employ westerners - which they did. As soon as a Libyan got the absolute minimum hours for command they booted out a westerner and replaced him by a Libyan. This was part of the 'Libyanisation' of the company in the best traditions of such nations. There was no real training department, and all checks were done on a pass/fail basis by outside agencies at various sim centres round Europe - ie no marks were awarded as would be the case elsewhere so managers, even if they cared, could not pick up trends and minimum level passes etc. A go-around was regarded as an 'emergency manoeuvre' that was tantamount to failure. Therefore to actually find yourself in one was a big deal - again very different to most western companies where a properly-executed go-around is a non-event in terms of management perception. One day it became apparent that no one was LVO qualified - the next week every single pilot received a certificate in his drop file to formally qualify them for LVOs. It certainly is one way of avoiding all that nasty training cost associated with LVO training. The final observation he made was that selection of Libyan pilots was almost exclusively on who you knew and absolutely nothing to do with ability. He said the Libyan pilots, particularly the FOs, were idle layabouts who made no effort to improve their professional knowledge or standard of English. They were an embarrassment but were kept on because they could not be seen to lose face and bin them.

If these tales are true, and I have no doubt they are, we should not be the slightest surprised at what happened on this flight. Some people reading this will be offended and see this as anti-Libyan or anti-Arab. My statement to them would be that this is factual, as is the appalling report just released. I have one glimmer of hope here - the fact that such a dreadful flight has been released into the public domain is a little sign that someone, somewhere in Libya may actually have a sniff of professionalism and want this never to happen again. More importantly, they may even take action to ensure it does not happen again.

[fantom]

Endorsed.

In the 320 sim with the fleet manager conducting and me, left seat, with f-w FO (won't mention the country, but Arab) in the right seat, the FM smacked me on the head and said: 'the next mistake he makes, I'm gonna blame you'.

It's all to do with 'saving face'. Don't ask.

True story.

[aterpster]

Capn Bloggs:

You must be Amercian, Terps. I only downloaded the first part and it opened OK. Hit the ground doing 260KIAS at -4400ft/min sink, captain on the controls. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/sowee.gif

Upon the advice of a friend I downloaded the latest version of Acrobat Reader. Problem solved.

[PJ2]

CATIIIBnoDH, Kalium Chloride, thank you for posting links to these valuable documents and presentations concerning this accident. They provide support for impressions left upon reading the accident report that the organization's safety processes, standards / training / checking processes and internal as well as regulator oversight processes which are expected to be part of airline operations were in fact minimal or entirely absent.

The Dutch Safety Board response, dated November 29, 2012 to the CAA's draft report is respectful of the fact that the report was produced under challenging circumstances. The Dutch Safety Board correctly observes however, that the report provides only limited discussions concerning these factors.

Some have commented that there is nothing to learn from this accident because we've seen it all before and some have even cited other accidents such as Colgan and AF447. The thing most obviously remaining to learn is of course, that there remains things to learn because this kind of accident happened again.

Elsewhere in PPRuNe there is a discussion on CRM, and the view expressed that it is over-rated because "good pilots" always already practice good communications naturally. While I agreed that pilots who were deemed good at their job were also good communicators, not all cultures practice communications and personal relationships in the same way particularly in command-and-control circumstances and so the formalization of communications techniques which convey important safety information in a timely manner either in the organization or the cockpit in neutral but effective ways is sometimes needed, as is clearly demonstrated in this accident.

Flight data analysis is also very briefly mentioned in the report but the program was not functioning at the airline, (nor was FOQA implemented/functioning at Colgan prior to their Buffalo accident and my bet is that it still isn't operational...another thread). This is the clearest example of the value of data analysis by trained, experienced people who know flying. The fact that the same crew did the same thing two weeks prior to the accident and the airline did not know is, I think, inexcusable in modern transport operations.

I look forward to the Dutch Safety Board's further responses to the CAA's limited work.

Artic flyer, interesting view because it sets aside the notion of "somatogravic" as a root cause and forces examination of other factors which come under the general heading of 'competence'.

[PEI_3721]

This accident is similar to incidents 2, 3, 5, and 6 (http://www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf) with respect to the early descent and failure to crosscheck altitude against distance (DME) or the locator check altitude. Again note the lack of an altitude / distance table (charted or operator provided).
These contributed the surprise of the unexpected EGPWS alert, where the problems of the GA started.

[CONF iture]

He said the Libyan pilots, particularly the FOs, were idle layabouts who made no effort to improve their professional knowledge

For sure something was missing after messing up that same approach 2 weeks before.
As a crew, on their own initiative, did they review what they did at the time and what they should have done ?
I doubt it or they would have been much more prepared to execute what has been their last approach.

An FDM program is excellent, but no pilot should wait to proceed to his own auto critics.

[LandIT]

The Co-pilot initiated the GA, climbed to 600' and that seemed to be going OK until suddenly the Captain took over and dived. Did he see the runway then and dive for it? (Had he just realised they made the same early descent as last time they were together, and all they had to do was get down again, fast now?) Very interesting other posts about training, competence and loss of face. Especially at one's home airport after being on the aligned approach, when after all "the runway is down there ahead somewhere - we just have to get low enough to see it". How tragic this crew had screwed up before - did this contribute to the captain's actions? Can't this be a lesson to us all - minimums are minimums for a good reason. If you can't see the runway, perhaps there is a good reason for that. Go around. Once you are going around, go around!

[lederhosen]

I don't think putting up the gear, cleaning up and accelerating to 250 knots while descending at 4000 feet per minute is compatible with trying to continue to a landing. They plain and simple lost control. The report makes the valid point that two engine go arounds do not appear to have been practised much during their training. However they do not seem to have absorbed very much of their training, so whether it would have made much difference is not clear.

[CONF iture]

Why did the FO quit the MANAGED approach that was by far the easiest to proceed with ?
They had already FINAL APP on the PFD and probably the blue arrow somewhere 1/2 a NM after TW NDB to indicate the start of the -3 degrees slope from 1400 ft.
The SELECTED approach needed more thinking and about -2.5 degrees FPA from TW if level at 1400 ft.
The report does not say how often the 330 guys at AFRIQIYAH Airways are used to proceed for non precision approaches on their network ...
Those non precision approaches on the Airbus are nice to fly but do need regular practice to adequately master them.

[AlphaZuluRomeo]

The Co-pilot initiated the GA, climbed to 600' and that seemed to be going OK until suddenly the Captain took over and dived.
This is not what I read. Both "dived".
First the F/O then, when the pitch was already ~3° nose down, the CPT took priority and "dived more" at a time when the F/O changed his mind and began to pull his stick nose up.

Why? Perhaps...

As part of the investigation, the model for estimating the perceived orientation was used with SSFDR parameters. The figure below shows that at the time of the missed approach, the attitude perceived by a pilot, provided that his perception is based exclusively on the interpretation of vestibular inputs (without external visual reference and without monitoring the artificial horizon), is initially close to the real attitude. It then deviates from the actual attitude from about 11 degrees to increase and remain between 15 and 22 degrees nose up. The first nose-down inputs recorded for the co-pilot's side stick occur at a moment corresponding to this deviation. The difference observed between the actual attitude and estimation of the perceived attitude may be related to the occurrence of a somatogravic perceptual illusion.

[RatherBeFlying]

the attitude perceived by a pilot, provided that his perception is based exclusively on the interpretation of vestibular inputs reminds me of Kennedy flying into the ocean in a dark misty sky.

Sometimes you need to be on the instruments in legal VFR.

[Octane]

The barely disguised sarcastic undertones in the Dutch response to the draft report suggests they believe the Libyan crew in question would have had difficulties putting a Tiger Moth down in one piece. The mind boggles......

[rogerg]

In my experience, as a simulator instructor, the most accidents occur with an all engine GA. With lower power, ie one engine failed, most problems are sorted.

[PJ2]

The barely disguised sarcastic undertones in the Dutch response to the draft report suggests they believe the Libyan crew in question would have had difficulties putting a Tiger Moth down in one piece. The mind boggles...... 3rd Mar 2013 20:00
I don't think the Dutch response is sarcastic at all. I think it is a frank, honest response to an inadequate and limited examination of why this aircraft crashed.

If questions are raised in the Dutch response they are not about just one crew, they concern Afrikiyah's capacity to prevent another accident.

In this the Dutch are doing Afrikiyah an enormous favour by helping them learn from what occurred.

A Libyan response to the Dutch Safety Board is not only warranted, it is the only thing that will permit the airline to learn and therefore become safer.

[CONF iture]

In my experience, as a simulator instructor, the most accidents occur with an all engine GA.
What kind of 'accident' do you have in mind ?

IMO the main thing with GA in simulator, is that a simulator cannot render that tricky somatogravic perceptual illusion, which is the strongest when all engines are pushing. Should we go once in a while practice a real GA under the cap to realize what is behind that illusion ... ?

[rogerg]

I learnt a long time ago that you have to fly the instrunents. All the various "illusions" have to be ignored. This is a basic tenet of instrument flying.

[A-FLOOR]

What kind of 'accident' do you have in mind ?

IMO the main thing with GA in simulator, is that a simulator cannot render that tricky somatogravic perceptual illusion, which is the strongest when all engines are pushing. Should we go once in a while practice a real GA under the cap to realize what is behind that illusion ... ?If you think for a minute, you will realize a simulator's motion system actually does this very thing: it uses the principle of somatogravic illusion to simulate sustained longitudinal acceleration or deceleration while standing still.

[CONF iture]

If you think for a minute, you will realize a simulator's motion system actually does this very thing: it uses the principle of somatogravic illusion to simulate sustained longitudinal acceleration or deceleration while standing still.
It is limited what a sim can reproduce in terms of intensity and duration in the time. As a matter of fact how often a crew in the sim will succumb to the illusion during a GA practice to the point to hit the ground at the Afriqiyah's way ?

[Capn Bloggs]

As a matter of fact how often a crew in the sim will succumb to the illusion during a GA practice to the point to hit the ground at the Afriqiyah's way ?
The "surprise" factor should also not be forgotten. In the SIM, you're all set for something to go wrong, going through the GA manoeuvre in your head, ready for it, and when it comes you're on the clocks sweating on good attitude and speed control. On the line? Maybe not as much...

[jcjeant]

The "surprise" factor shouldA go around can't be a surprise .. this is something planned well in advance like aborting a take off .. it's something provided
If suddenly a wing snap off .. we can indeed consider that there will be a surprise

[A-FLOOR]

It is limited what a sim can reproduce in terms of intensity and duration in the time. As a matter of fact how often a crew in the sim will succumb to the illusion during a GA practice to the point to hit the ground at the Afriqiyah's way ?Intensity perhaps, but duration, no. This is my point: while all other accelerations (linear and rotational) are time limited depending on the stroke of the motion system, this is the one thing simulators are able to simulate indefinitely just by changing the gravity vector, using the somatogravic illusion in reverse and rotating the cab around an axis which is aligned with the flight crew's inner ears. I don't have the data handy how quickly an A330-200 will accelerate in a normal GA, but I'm fairly sure this figure is well within what the X-axis low-pass motion filter can produce, with room to spare for pitch changes. Besides, isn't the fact that crews in the sim will succumb to the same illusion in itself a testament to the sim's fidelity in this particular situation?

[IcePack]

IMHO all that happened is that PF decided to pre - select his FPA and pulled in error (got confused with the automatics) after that no one monitored anything.
From the vid the PF pulled the gear so time capt caught up he was also in the wrong place in his mind. Lots will say we'll I wouldn't have done that. That is until something similar happens to you. I was watching a training capt debriefing a cadet a while ago saying he had never done a rushed approach. I resisted the urge to but in and ask if that was apart from the one he did with me when he was a first officer. Please remember we are all human. Good training is the key & I expect this crew did not get a lot of that.

[Gnadenburg]

Pitch-down inputs were applied for 21s, causing the A330's pitch attitude to reduce to 3.5° nose-down. The inquiry suggests the co-pilot was focused on the aircraft's speed, rather than its attitude, following an incident 14 days earlier when an overspeed warning activated during a go-around.


As the aircraft lost height the terrain-awareness system issued a succession of sink and ground-proximity warnings. But the captain responded with a "sharp" nose-down input, says the inquiry, adding that he might have been subject to somatogravic illusion or was similarly focused on the A330's speed.




This seems to suggest another illusion at play to do with the aircraft's PFD speed tape presentation. To be focused on an overspeed, yet pushing nose down.

Does anyone have anything further on this?

[Lyman]

Gnadenburg

This seems to suggest another illusion at play to do with the aircraft's PFD speed tape presentation. To be focused on an overspeed, yet pushing nose down.

Or, focused on overspeed and Pull? In spite of Stall Warn? At cruise?

Hyper-focus...can happen to anyone. Anyone.

[barit1]

I haven't read the report - what were the autopsy results?

I'm thinking of a L-188 military charter flight in the 60s in which the PF (also president of the airline) suffered a medical emergency on short final and fell over the control column, driving the aircraft into the ground.

[anotheruser]

thinking of a L-188 military charter flight in the 60s in which the PF (also president of the airline) suffered a medical emergency on short final and fell over the control column, driving the aircraft into the ground.I guess that's something that can't happen with good old sidesticks ...

[Lyman]

All belts fastened and snug?

[thermostat]

From the Dutch report, it seems to me there was a total disregard of procedures and no CRM. The FPA should have pulled at the "TW" FAF, not before as happened. No cross-checks either.
I would like to see a copy of the approach plate. What is the touchdown zone elevation for 09? I have noted some reference to a FPA of 2.5 degrees. Is this correct or should it be 3 degrees?
Some info please.

[CONF iture]

Some info please.
Have a better look to the report, most of the info you're looking for is included.

The FPA should have pulled at the "TW" FAF, not before as happened.
The FPA should not have been pulled at all.

[Gnadenburg]

Gnadenburg

Quote:
This seems to suggest another illusion at play to do with the aircraft's PFD speed tape presentation. To be focused on an overspeed, yet pushing nose down.
Or, focused on overspeed and Pull? In spite of Stall Warn? At cruise?

Hyper-focus...can happen to anyone. Anyone.

I think comparing (?) this to Air France and the unreliable airspeed scenario is tenuous.

Can anybody give an explanation as to why the crew are focused on the speed tape?

[Lyman]

Then how about the L1011 crew, staring at a bad 'bulb' into the swamp?

Preoccupation, distraction, hyperfocus, a family of bad and deadly habits.

Narrowmindedness? Losing the picture?

[DozyWannabe]

The EAL401 crew believed they were in AP altitude hold until the very last seconds - the situation doesn't compare.

[jcjeant]

Hi,

DW
The EAL401 crew believed they were in AP altitude hold until the very last seconds - the situation doesn't compare.
This is not about the situation ..
It's about distraction .. focusing .. forgetting all but one thing
That can happen in any situation .. and not only on a aircraft ...

[lederhosen]

Interesting report just released on a serious incident with an Air France airbus on approach a year ago.

[jcjeant]

Hi,

Interesting report just released on a serious incident with an Air France airbus on approach a year ago.
Where ?
Nothing on the BEA pages

[Clandestino]

Avherald, but don't worry, we will soon have long and winded thread about it here, mostly with contribution coming from people very opinionated about Airbi being deathtraps by design, AF pilots being on par with Nigerian and BEA being part of masonic conspiracy including Airbus and Republique Francaise, yet they will display amusing inability to positively differentiate autopilot and flight controls.

[DozyWannabe]

This is not about the situation ..
It's about distraction .. focusing .. forgetting all but one thing
That can happen in any situation .. and not only on a aircraft ...

Whilst I agree with what you're saying in principle, the fact that Afriqiyah 771 was deliberately placed under manual control and then mishandled - whereas EAL401's departure from controlled flight was inadvertent, is an important distinction to make.

The PF on 771 may have been distracted in terms of his scan breaking down, but he knew he was in control. The crew of EAL401 were working on the assumption that the autopilot was in control - the PF's mistake there was using the autopilot function display in lieu of an instrument scan while they were troubleshooting the bulb. He didn't know that George (and by extension he) wasn't in control until it was too late.

Distraction or tunnel vision is in all likelihood a factor in both, but the difference in the nature and degree of distraction makes it a dicey comparison in my book.

[lederhosen]

For those unfamiliar with the french language the highlights:

1. Approach at 4.50 A.M. at Paris CDG exactly one year ago
2. Airbus A340 cleared for a CAT3 approach
3. 250 knots at FL90 at 30 miles
4. Cleared to intercept the localiser
5. Due to somewhat delayed clearances intercepted the glide from above
6. At 9 miles 4950' (1750' above glide)
7. At 2 miles still 1600' above path
8. The aircraft then did some interesting stuff which the Airbus experts can no doubt explain, but (at risk of a flaming) seems very strange
9. The crew eventually sorted out the modes went around and landed normally

Interesting comparisons with Afriqiyah would be the combination of possible fatigue, poor approach execution and confusion during go-around.

[lederhosen]

There was not just confusion from the avionics. The aircraft pitched up to 26 degrees and the speed reduced to 130 knots going from 1600 feet per minute descent to 3300' feet per minute climb with the speedbrakes out? Thrust was then reduced to idle. I think an interesting point is that apparently experienced Airbus pilots can get so seriously out of the loop.

[jcjeant]

AF pilots being on par with Nigerian and BEA being part of masonic conspiracy including Airbus and Republique Francaise, yet they will display amusing inability to positively differentiate autopilot and flight controls. Yes indeed ! :)
Why Air France should be banned from non-EU skies | Plane Talking (http://blogs.crikey.com.au/planetalking/2013/03/13/why-air-france-should-be-banned-from-non-eu-skies)
For an account of appalling flight safety standards in a major airline (http://avherald.com/h?article=45f1317a&opt=0), a French air safety agency (BEA) report into a seriously botched approach to Paris Charles de Gaulle airport by an Air France A340 a year ago today is hard to beat.
A lay translation as to what happened would be that the crew persisted in making an unstable and excessively high and steep descent toward landing which caused the aircraft at one stage to risk stalling as the nose pitched up in an excessively steep attitude while the speed fell away.
There is no excuse for such a situation to have arisen. The report makes a lame attempt to put part of the blame on the controllers in the CDG tower, but the inescapable truth for Air France is that it is responsible for the flying culture and safety standards of its pilots and that this flight tells us this airline has hadn’t found in 2012 the plot it lost in 2009 when AF447 went down.A starting point would be to insist that the French safety investigator, the BEA, reverse its refusal to release the full transcript of what was said between the three pilots in the cockpit of AF447 (http://blogs.crikey.com.au/planetalking/2012/12/29/af447-report-needs-a-human-factors-reappraisal/) .BEA report:
http://www.bea.aero/docspa/2012/f-zu120313/pdf/f-zu120313.pdf

[Gnadenburg]

Can anybody offer a translation from French as to what was so bizarre about the go around?

[CONF iture]

The problem was not the GA.
As the crew was way above the normal 3 deg GS, the airplane tried to intercept what is called a secondary GS which is at 9 deg. This happened when the APPR was armed by the crew, and G/S* became the active vertical mode. The airplane was allowed to take an aggressive 26 deg pitch before the AP was disconnected.
I can see a similitude with the 330 accident in Toulouse when ALT* became the vertical active mode and the capture of the altitude became the priority whatever the speed.
They would have gone to the stall too in CDG.

The crew did not follow the recommended procedure to intercept the GS from above, they were behind their airplane and got caught by the automation.

[BOAC]

Someone please explain why the a/c decided to pitch 26 deg nose up when above the GP? Is that what G/S* does?

[CONF iture]

The airplane was interested in the secondary GS, the one at 9 deg.
And actually it was already above that 9 deg GS, but as that signal is inverted by conception, the airplane was looking for the moon.
It would be interesting to know if the protections would have intervened at some stage ... but the report is mute on that point.
I am also surprised by the agressivity of the G/S* ...

[Clandestino]

We are amazed at the discovery of the false glidepaths and that on a site that has "Professional Pilots" in its title. Wow!

[BOAC]

Actually, conf, my understanding is that the 9 deg G/S is the 'tertiary' G/S and is CORRECTLY sensed? For me the a/c would only be "looking for the moon" if it had passed through the 9 deg to the 6 deg, which begs the question...........??

Really not enough information here to decide WTF the autopilot was doing, and as for a crew using A/P in that situation - words fail me. AF - again! Where is this concept coming from that the a/c system is infallible and the A/P will sort it out? It needs stamping out pronto and ALL pilots told either g/a or take over manually until you are 'in the groove.' (No 1 in this case!) If lederhosen's figures are correct
"6. At 9 miles 4950' (1750' above glide)
7. At 2 miles still 1600' above path"

the LAST thing I would do is plug in the A/P in G/S capture.:ugh:

and from AvHerald
" at 4nm before touchdown the aircraft was at 3700 feet MSL and 2100 feet above glideslope" and
"At about 2nm out, the aircraft descended through 2850 feet MSL 1600 feet above glide, the vertical channel of the autopilot mode change glideslope capture and autothrust changed to speed mode." - more confirmation (if needed) that AF have huge issues in crew standards to address, if Jaques and Pierre are confident it has captured the G/S...........

However - one re-assurance - at over 2300' ABOVE the threshold
"The pilot monitoring recognized the modes announciated were not suitable....."

:mad: Is the whole airline UNABLE to fly an aircraft?

[CONF iture]

Actually, conf, my understanding is that the 9 deg G/S is the 'tertiary' G/S and is CORRECTLY sensed?
Not according to the BEA report, the 9 deg GS is a 'secondary' GS and its signal is inverted. The 6 deg GS is also a 'secondary' GS but with no associated signal. If you look at the figure #4 on page 6 the UP arrows tell the AP to go up to intercept the glide. That information is correct for the 3 deg path but inverted for the 9 deg one.

For me the a/c would only be "looking for the moon" if it had passed through the 9 deg to the 6 deg, which begs the question...........??
If you look at the figure #1 on page 3 the aircraft was already above the 9 deg path when it started the pitch up.

the LAST thing I would do is plug in the A/P in G/S capture.
The AP was engaged all the way, only the second AP was later on selected for an ILS approach as per Airbus procedure. You could do everything manual (probably not for a cat3 though) but works well under AP too if appropriately commanded. Early on at 9000 feet 30 NM the situation was manageable if the correct steps were taken but clearly Pierre et Jacques were behind the aircraft on that night.

The good thing is that the PF finally disconnected the APs before the STALL (?) and pushed all the way on the commands.

[BOAC]

Well, conf, I have to say that BEA's opinion of false glideslope signals seems to differ from everyone else's - I have to say I have NEVER seen the animal, so cannot comment on how many and which 'polarity' they are but I have yet to see anyone OTHER than BEA claim no 'signals' at 6 deg and 'reversed' at 9.

However, "not really important right now" as the saying goes - a complete cluster *** whatever, but perhaps the expert clandestino can tell us exactly what happens to the lobes?

[CONF iture]

It seems that this crew has been into a wild territory where Airbus has never been before.
That possibility for such an aggressive pitch up at G/S* was probably unknown from Airbus.
The report just tells too little, I would like to know what would come next if the pilots are in a VERY bad day ... ?

[lederhosen]

A rough and ready response to Gnadenburg's request for a translation, rather delayed due to a trip.

When pitch reaches 26° the crew disconnect both autopilots and pilot flying applies nearly full sidestick forward. The pitch and vertical velocity decrease. The crew close the airbrakes. The thrust levers are positioned to IDLE. Speed ​​is 143 kt and ATHR disengages. About 30 seconds later autopilot 1 is engaged, thrust levers are set to climb and the auto thrust reengaged. The pilot flying said he selected autopilot 1 to make an automatic go-around.

Modes LOC and G / S are active and ATHR is in SPEED mode. Speed ​​is 147 kt. The plane is over the runway threshold at an altitude of about 2700 ft. The pitch decreases by 2 ° to - 5 ° and the plane descends. The pilot flying (commander) said he realized that the modes displayed on the FMA were not suitable. The autopilot is disengaged 8 seconds after activation then a pitch of about 6 ° is achieved and the thrust levers are set to the TOGA detent at an altitude of about 2000 ft.

So in summary a bit of mode confusion in the go-around but they got there eventually.

[blind pew]

Seen and flown the beast.
1980 DC9 - 51 rwy 05 GVA.
First month of training.
Direct approach avoiding the proceedure let down in turbulence and occ icing.
Outer marker check didn't make sense and thought we had mis set altimeters.
Realised what I had done - switched off FD and closed throttles then intercepted 3 degree slope from above.
Besides ROD (which I didnt notice) and power setting? Everything else normal.
Neither skipper or SFO safety pilot realised.

[737Jock]

Anyway did they close the thrust levers in order to help with lowering the pitch attitude I wonder? Or was it really mode confusion?

[lederhosen]

On the 737 that would certainly help in a high power situation. But in this case given the speed reducing to 130 knots it is not clear what the autothrottle was doing. The real mode confusion occurred when selecting the climb detent rather than TOGA. I seem to remember an A320 go-around at CDG where problems occurred when TOGA was not selected.

[737Jock]

I fly a320 currently lederhosen. All underslung engine aircraft have pitch-up effect with large thrust increase. Autotrim can't keep up with that.

This is one of the reasons why the stall procedure changed on airbus aircraft, first break the stall with pitch, then slowly add power.

http://www.airbus.com/fileadmin/media_gallery/files/tech_data/AC/Airbus-AC_A340-500_600_Dec11.pdf

Page 3-5-0/1:

I imagine that typical a340 speeds are in the 135-145kts region. Its normally a CAT C approach category aircraft.

[blind pew]

And hit the ground!
What's wrong with stick and throttles fwd?

[737Jock]

Stalling is wrong with that blind pew...

Stick and throttle forward can be wrong in some circumstances, engines at full power can prevent the pitch from coming down sufficiently to prevent a stall, or might even deepen the stall. You might want to read up on a 737 incident in the UK.

There is no single recipe for success in abnormal attitude situations. Fact is that stall procedures have changed all over the industry, to first break a stall with pitch, then to slowly add power to prevent secondary stalls as a result of pitch-up effects.

I'm not saying that their actions were correct, just providing an alternative to why they might have lowered the nose and simultaneously closed the thrust levers.

I once heard from an engineer that on an (A340 or maybe 330) during test flight, they deep stalled the aircraft and could not get out of it. Even with the engines at idle they had to shutdown one engine to allow enough pitch control to recover and counter the pitch effect. No reference unfortunately. So all hearsay really, anybody heard something like this?

The key is to not allow these situations to happen at all, but once they do there is no single recipe that will solve all problems.

[blind pew]

Always thought one initial proceedure is the way to go...then if the nose doesn't come down take some power off.
After all if it takes 8 secs from idle to get a decent amount of thrust then by trickling it on one could looking at twenty seconds which is an awful lot of altitude.

[737Jock]

blind pew... the new procedure on all airbus and boeing jets is to first lower the nose and break the stall. Only when out of the stall power gets slowly added, to prevent a secondary stall.

That is the manufacturer procedure! Or one initial procedure as you might like to call it!

Don't agree?.... go and talk to mr. Airbus and mr. Boeing!

The way to go is to get nowhere near a stall!

[deptrai]

FAA stall recovery template from AC 120-109 - Stall and Stick Pusher Training (http://www.faa.gov/documentLibrary/media/Advisory_Circular/AC%20120-109.pdf)

1 Autopilot and autothrottle………………………………..Disconnect

2 a) Nose down pitch control… Apply until stall warning is eliminated
b) Nose down pitch trim…….………………………..….As Needed

3 Bank…………………………………………………..…….Wings Level

4 Thrust …………………………………………….………….As Needed

5 Speed brakes/Spoilers……….…….…………………………..Retract

6 Return to the desired flightpath.

rationale for each step - including 4) Thrust - is provided in the AC link above :)

I won't quote the entire document, but obviously some caveats... The manufacturer’s procedures take precedence; Manufacturers are expected to deviate from this template if the airplane operating characteristics require, and This AC does not provide guidance for full aerodynamic stall training (because more will be forthcoming...but the FAA emphasizes training should treat an “approach-to-stall” the same as a “full stall”).

[blind pew]

Written by non flying lawyers in the days after "airmanship", "handling skills" and "pilot" were withdrawn from the Oxford dictionary.:mad:

[lederhosen]

It is always interesting to compare notes on how critical situations are handled in different companies. As 737Jock has indicated the stall recovery has been changed to breaking the stall and then increasing power. However I can find no reference to selecting idle thrust (reducing thrust as necessary to get the nose down yes). The Airbus guys can no doubt confirm why you might do this. But if you have disconnected the autothrottle I cannot see the obvious reason for pulling the thrust levers all the way back with gear and flaps down, recovering from a low level approach to a stall.

Selecting the automatics on shortly after recovery to carry out the go-around while still in approach mode was clearly wrong and led to further gyrations. No set of procedures can cope with every eventuality and common sense is needed. I go back to the thought that for all its obvious strengths the Airbus way of flying can lead to the pilot being that much further outside the loop. When combined with fatigue and relative little hands on flying due to long haul this can be a problem. Do Air France do mixed fleet flying?

[deptrai]

Written by non flying lawyers in the days after "airmanship"

Well this is an FAA template, I quoted it because it illustrates some of the points mentioned, and applies to most large transport aircraft. Some parts may contain lawyeresque bureacratese (and I quoted some of that too to prevent "the new breed of pilot" as some put it, from mistaking pprune to be an authoritative source), but the stall recovery procedure seems clear to me, for illustration purposes, and the document is signed by the guy in charge, John Allen, who logged 4800 flying hours, mostly as an Air Force C-141 instructor, and holds an ATPL which also has an A320 rating. I think he has a basic grasp of what it takes to pilot an aircraft, and the world isn't falling apart yet ;)

[blind pew]

Obviously besides not being proper pilots they know nowt of history or training.
Stick fully forward.
Full power
Revert to fully manual control - ie dump auto pilot and auto trim.
Check configuration (gear, brakes, flaps and slats).
If stall persists then trim forward and consider approroate thrust reduction and configuration change.
Still no luck then apply bank whilst transmitting"what a heap of s@@t this Airbus or Boeing is" - delete where appropriate.
Scratch onto nav table suitable depleteives that blame the training/management dept.
(Ref. Staines inquiry 1972).

[misd-agin]

Obviously besides not being proper pilots they know nowt of history or training.
Stick fully forward.
Full power
Revert to fully manual control - ie dump auto pilot and auto trim.
Check configuration (gear, brakes, flaps and slats).
If stall persists then trim forward and consider approroate thrust reduction and configuration change.

Scratch onto nav table suitable depleteives that blame the training/management dept.
(Ref. Staines inquiry 1972).


Stick fully forward and apply full thrust? No, that's from the guys that think everything flies the same or havn't had the benefit of up to date training/test experience, or accident/incident investigation, in modern jet aircraft.

deptrai listed the correct procedure.

[deptrai]

I think blind pew posted some tongue-in-cheek comments that should be taken with a grain of salt ;) At least it made me chuckle.

the FAA guidance is of course correct, and as misd-again points out, state-of -the-art, current wisdom. Which reminds me of this book I've been wanting to read "The Half-life of Facts: Why Everything We Know Has an Expiration Date".

[737Jock]

Blind pew you seem to be an old fart that doesn't realise that nose forward and full thrust have led to some very frightening situations. Such as not being able to unstall the aircraft, secondary stalls etc etc.
Which is also the reason why people might reduce the rhrust to idle -> it provides an immediate nose-down effect.

Was this correct in the AF situation, I sincerely doubt it but I don't fly A340 nor have been trained by AF. Was it horrible? No they were in normal law.

And blind pew talking about airmanship/skills etc etc to defend your argument for your suggested stall recovery (which is outdated)....... But then I wonder: Why did this person even stall if those qualities are so greatly developed???

[blind pew]

Of course that goes without saying.
But I guess that you have never flown DC8s which had a huge pitch - power coupling. Nor got bored with teaching aerobatics and mountain flying.
Then I would also guess that your knowledge of physics isn't the best.
The stall/ terrain equation is about managing energy.
Hydrocarbons need to be converted to potential and kinetic energy.
A stalled aero foil is way on the backside of the drag curve - one needs to get energy into the equation - either from potential - IE throw away altitude or by converting HC to thrust.
The most critical phase is close to terrain so the obvious solution is pitch down and full power - the later takes TIME which you might not have enough of. If the pitching couple is too great then you can always reduce it.
But if you had flown something like a DC8 or a 707 you would know how critical the trim is and you would be winding it forward at the same time as you push the stick and throttles forward.
At altitude the power pitch couple is far less (back to physics again) and you have more time anyway.
Then we have time for the niceties of configuration and limits.

The A340? Story about shutting an an engine down is NOT true.(from a senior airbus pilot yesterday - although his reply was rather more colourful).

Those readers of my generation would remember the huge wheels with a white mark and a klaxon which drew your attention whenever they spun. The memory drill to inhibit their movement in the event of a runaway because of the (true) stories of what could and did happen.
Sensible use and observation of the trim was part of airmanship that old farts of my generation were taught.
But then again it took me 300 hours and two years to get into the RHS which the powers that be considered to be marginally enough experience (quite rightly so) and that was on a three crew airliner.
But then again we was pilots and play station hadn't been thought of:ok:

[Capn Bloggs]

Stick fully forward and apply full thrust? No, that's from the guys that think everything flies the same or havn't had the benefit of up to date training/test experience, or accident/incident investigation, in modern jet aircraft.

deptrai listed the correct procedure.
No for all types, he didn't. That's only a template (obviously biased for "modern" underslung engine types) and is not the correct procedure in the many cases where the engines are on same level as the C of G.

[BOAC]

What is this modern fad for making all flying into a 'corn-flake packet cut-out' kiddies' template?

Firstly, 99% of all airline 'stalls' are not stalls but stall warnings, because that is where you 'recover' in the sim and I'll wager most pilots will for real.

Secondly, as Pew knows, if you are 20kts below Vref at 100ft and you have a stall warning, lowering the nose, levelling the wings and thinking then about applying power will guarantee a touchdown earlier than you hoped and probably not too good.

All this froth came about because silly trainers got in their minds to INSIST on minimum height loss in stall recovery, including at high altitude. There is no such thing as a 'standard' stall recovery - you do what is needed. If the wing is STALLED you MUST reduce AoA regardless. If it is power you need at low altitude you apply it, in a sensible amount, ready to reduce it if you have the 'underslung' looping tendency, but power you will need. If you are at altitude, you can trade height for speed. As with many other facets of 'committing aviation', some understanding and realisation of the situation is needed rather than a blanket response.

[737Jock]

Hmm blind pew, you are the one suggesting one recipe for every situation. Which really suggest that you have a very limited idea of physics!

No I had the pleasure of flying 737's which has a huge pitch power coupling...

I'm not impressed with your CV, sorry buddy! But I have met guys with loads of experience, in various areas including fast jets, who are absolute crap!

Again the name of the game is to not get anywhere close to a stall, once you are in a stall in a commercial airliner you ****** up big time! Its no use to start fending with airmanship or manual flying skills at that stage, cause you just proved their not all that!

In the airframce case they weren't close to a stall. But due to the aerodynamic build of the aircraft the horizontal tail of the aircraft is actually a bit too small. Like an MD-11!
Smaller tailplane is more efficiency, and this is no problem under normal circumstances. However it also means that you might not have enough pitch authority at low speeds, to counter the pitch up effect of underslung engines at full T/O thrust.

Which is why the current manufacturer procedure is to break the stall with pitch, and gently add energy through the engines. So yes you might loose a bit more in recovery, but not nearly as much as you would lose in a secondary stall. And if you happen to find yourself in this situation at 100ft, well pray to god and and add thrust as quickly as possible. But personally I have never seen a stall recovery from a full stall in a jet in less then 100ft with full t/o thrust!
Did you happen to ask the senior airbus guy about this manufacturer procedure as well? Or did selective memory trouble you? Or maybe the guy is a figment of your imagination?

Sorry buddy, but I told you the A340 story about shutting an engine down was hearsay. So the colourful response aside, you are really barking up the wrong tree!

[blind pew]

Jock - twaddle
But due to the aerodynamic build of the aircraft the horizontal tail of the aircraft is actually a bit too small. Like an MD-11!
So the frogs and the yanks certify aircraft with "tails" that are too small?
Gosh you obviously know as much about aerodynamics as you do physics.

[737Jock]

Stall Recovery
Applicable to: ALL
As soon as any stall indication (could be aural warning, buffet...) is recognized, apply the immediate actions:

NOSE DOWN PITCH CONTROL APPLY
This will reduce angle of attack

Note:
In case of lack of pitch down authority, reducing thrust may be necessary.

BANK WINGS*LEVEL

When out of stall (no longer stall indications) :
THRUST INCREASE*SMOOTHLY*AS*NEEDED

Note:
In case of one engine inoperative, progressively compensate the thrust asymmetry with rudder.

SPEEDBRAKES CHECK*RETRACTED
FLIGHT PATH RECOVER*SMOOTHLY

If in clean configuration and below 20*000*ft:
FLAP 1 SELECT

Note:
If a risk of ground contact exists, once clearly out of stall (no longer stall indications), establish smoothly a positive climb gradient.

My bold, this is directly from the A320 QRH. Clearly they considered terrain impact.

Take it up with the manufacturer blind pew... Or the senior airbus guy:E
Obviously they should talk to you!
But any crew who allows their aircraft to stall, had better follow the manufacturer procedure or they will be hung, quartered and drawn.

TOO small may be overstated, but there certainly isn't any slack in modern aircraft design. And insufficient pitch authority is not unheard of unfortunately.

[BOAC]

In the airframce case they weren't close to a stall.- yes, jock - twaddle. What do you call 40 degrees AoA?

[blind pew]

BOAC - obviously secondary effect of too small a Horizontal tail :)

[737Jock]

40 degree aoa?

http://www.bea.aero/docspa/2012/f-zu120313/pdf/f-zu120313.pdf

Aren't you thinking of AF447?

The A340 incident reached a pitch of 26 degrees and an IAS of 130kts... Thats not a stall! And they never went below 2000ft!

Lets not let that sort of detail or actually reading what is being discussed get in the way of a good trashing however!

Maybe you guys should date... something like this (http://www.aaib.gov.uk/publications/formal_reports/3_2009_g_thof.cfm) would/could never happen to you I guess.

Unfortunately you are retired, so aviation is left with mere mortals. And therefore the manufacturers had to change the stall procedures...:ugh:

[BOAC]

Yup - misread your posts- sorry.

[737Jock]

Thanks BOAC.

[blind pew]

Know rather a lot about incorrect and foolish stall training as it became a personal interest after my best mate died in Britain's worst stall accident.
Ill thought out proceedures, incorrect training, maintenance, back dated paperwork, apparent amnesia at the inquiry...the list goes on and YET some of the practices continued for another 14 years.
Witnessed a couple of transient stall warnings which were put down as false but turned out otherwise after the FDRs had been downloaded.
Then I taught stalling and spinning for 15 years including Occasional demos below 1000ft.
And last month I booked up for a course to stall my paraglider - over a lake with a rescue boat and medics - just incase I get it wrong.
So whilst I might be an old fart I do have a little bit of experience and still believe that you teach one basic automatic recovery - stick forward and full power followed by the niceties and evaluation.
I was taught that in 1970 and the following year found myself upside down in a Baron with my nav kit on the ceiling following a clean 1G stall - worked perfectly.

[tubby linton]

Jazzhands, the A343aircraft was only on Flap 2 and was around 163kt before the pitch up. The speed to me sounds about right for F speed but obviously it varies with weight. F in approach config is 1.3 *VS1g which gives a stall speed of 125kt but the g may have been slightly higher as the aircraft rapidly pitched up.
Jock you have quoted the stall recovery procedure but as the A343 was in normal law it would of course have gone into alphaprot so your procedure would not have been applicable.
The report seems to lack a lot of detail. I could find no time scale only a distance from the threshold.There is also sparse information about the AP/Athr modes at specific times. I wonder what happened to the crew involved?

[737Jock]

Wow you stalled a baron, and a paraglider...
And you had a mate who died in the worst stall accident... AND you taught stalling and spinning in piston aircraft...

Obviously you are the expert on stalling a 300ton jet! Please contact airbus and Boeing ASAP I'm sure they need your expert consultancy on the matter!

[737Jock]

So whilst I might be an old fart I do have a little bit of experience and still believe that you teach one basic automatic recovery - stick forward and full power followed by the niceties and evaluation.

Exactly what they did in the G-THOF 737 incident.
Turned out that stick forward was not enough! They required extra trim nose down as the elevators do not give enough pitch authority to counter the pitch-up effect from underslung engines.
On top of that because maximum thrust was asked, full power as you say, combined with a cold day: the delivered thrust exceeded the rated thrust.
This excess can be too large for the designed pitch authority.

And they started recovery before the stall warning! Thus airflow over the tail was greater then what would have been the case during a stall.

There is no single recipe for recovering from a stall in a jet. You need to be very careful with thrust during recovery.

[737Jock]

You also might want to read this report on the airbus accident in Perpignan:

http://www.bea.aero/docspa/2008/d-la081127.en/pdf/d-la081127.en.pdf

2.1.5 Loss of control
When the stall warning sounded, the Captain reacted by placing the thrust levers in the TO/GA detent and by pitching the aeroplane down, in accordance with procedures.
The nose-down input was not however sufficient for the automatic compensation system to vary the position of the horizontal stabilizer, which had been progressively deflected to the pitch-up stop by this system during the deceleration. The Captain controlled a left roll movement, caused by the stall. The aeroplane’s high angle of attack and the roll movements generated asymmetry, and a speed variation between ADR 1 and 2 appeared. This increasing divergence caused a rejection of the three ADRs by the FAC then the ELAC. The flight control system then passed into direct law. It is likely that the crew did not notice this due to the emergency situation and the aural stall warning that covered the warning of a change of flight control laws. The Air New Zealand pilot, by saying “alpha floor, we’re in manual” likely considered that the alpha floor function had triggered and that in fact the autopilot had disconnected.
The aeroplane rapidly regained speed under the dual effect of the increase in thrust and the pitch-down attitude. Under the combined effect of the thrust increase , the increasing speed and the horizontal stabilizer still at the pitch-up stop, the aeroplane was subject to pitch-up moment that the Captain could not manage to counter, even with the sidestick at the nose-down stop. The exchanges between the pilots at this time show that they did not understand the behaviour of the aeroplane. In particular, the aeroplane’s lack of reaction to the nose-down control input did not draw their attention to the position of the horizontal stabilizer and the loss of the auto-trim function.
The aeroplane attitude increased sharply and its speed dropped to the point that rendered it practically uncontrollable, the flight control surfaces becoming ineffective due to the low speed and the high angle of attack. The aeroplane stalled again, this time irrecoverably, bearing in mind the aeroplane’s altitude and without any crew inputs on the trim wheel and the thrust levers.
The loss of control was thus caused by a thrust increase performed with a full pitch-up horizontal stabilizer position. This position and the engine thrust made pitch down control impossible. It should be noted that the PF made no inputs on the horizontal stabilizer nor reduced the thrust and that the PNF did not intervene. This seems to indicate that none of them were aware that the automatic trim system, which relieves the pilot of any actions to trim the aeroplane, was no longer available. In the absence of preparation and anticipation of the phenomenon, the habit of having the automatic trim system available made it difficult to return to flying with manual trimming of the aeroplane.
It should be noted that even though, from a regulatory perspective, the limitations on duty time and flying time were respected, the length of time that the two XL Airways Germany pilots had been up, since waking before 4h30 for positioning, until the accident at 15 h 46, may have altered their performance during the flight, especially during the approach phase.


Due to the position of the stabilizer at full pitch-up and the pitch-up moment generated by the engines at maximum thrust, the crew lost control of the aeroplane during the increase in thrust.

And one of the recommendations that led to our new stall recovery procedures:
4.4 Approach-to-Stall Recovery Technique and Procedure
When the stall warning sounded, the crew reacted in accordance with the procedure for recovering from an approach to stall by applying full thrust to the engines and by trying to decrease the pitch angle. The moment generated by the application of full thrust to the engines and the pitch-up position of the stabilizer made it impossible for the crew to be aware of the situation and to recover control of the aeroplane. In addition, the manual use of pitch trim, which is not included as a reminder in the approach-to-stall procedures, only occurs very rarely in operation and occasionally in training. Several investigations undertaken following accidents and incidents (including that mentioned in 2.4) tend to call into question the procedures relating to approach-to-stall techniques for all types of modern aeroplane. Studies are currently under way with a view to improving these procedures.
Consequently, the BEA takes into account these elements and also recommends:
€ That EASA, in cooperation with manufacturers, improve training exercises and techniques relating to approach-to-stall to ensure control of the aeroplane in the pitch axis.

[lederhosen]

Come on 737Jock play the ball and not the man. You can read Blind Pew's book (easily findable with the search function) which tells us plenty about his credentials to comment, Trident, VC10, DC10 etc.

Your information in the two later posts is interesting. The Perpignan accident was of course a test flight where the aircraft did strange stuff for multiple reasons. The Icelandair 757 go-around in Oslo some years ago is another example of gyrations on go-around with a normal aircraft.

I raised the issue of the AF flight because of its parallels to Afriqiyah: wide body airbus, early morning arrival, misflown approach, confusion during the go-around. Its fine to disagree but lets treat fellow professionals as we would wish to be treated and get back on thread.

[blind pew]

Jock if you had read my post re stall recovery and what I was taught to do you would have discovered that elevator trim position was part of the scan and that if the beast doesn't do what you want it to do then you use other means such as trimming forward, reducing thrust, changing configuration.
Mate witnessed a mid air between a glider and a free fall parachutist...(another inquiry where false statements were made).
The glider pilots could not get out due to high G loads after wing tip sheared off.
In desperation they tried everything including airbrakes which altered the spiral dive and survived bailing out at 400ft.
The stall my mate got killed in had many causes - the principal was suppressing previous events, followed by incorrect stall recovery teachings, lack of understanding, general incompetence, fear of the aircraft and bullying.
A recent discussion with someone far better qualified than I am who had witnessed simulator crashes when "thrust as required" was not enough and too late said the new proceedure was the result of lawyer influence. He also insinuated that no one had the gonads to speak out.
Back to the old ways of everything is pilot error.
And as general interest re a couple of the stall warnings that I witnessed they were on the Trident which approached well on the backside of the drag curve at a higher speed than most aircraft of the era - we burst lots of dunlops as well - it was also due to a sluggish early autothrottle which we were not allowed to take out except in the event of an engine failure and probably in severe turb such as Heraklion or Gib with a southerly gale.

[deptrai]

said the new proceedure was the result of lawyer influence

interesting rumour. I don't have any inside knowledge. What I see is that manufacturers reacted to multiple wake-up calls, after incidents and accidents which we have all read about, by revising their procedures, and the FAA bases their guidance on collective industry knowledge. Boeing states:

"Most approach to stall incidents have occurred where there was altitude available for recovery. The incidents that progressed into accidents often occurred because the crew failed to make a positive recovery when the stall warning occurred, the condition progressed to a full stall, and the airplane impacted the ground in a stalled condition. For this reason, emphasis has shifted from a recovery with minimum loss of altitude to reducing the angle of attack below the wing stalling angle to complete a positive and efficient recovery."

IFALPA also revised their best practices (http://www.ifalpa.org/store/IPTS.pdf) guide. I don't think it's a lawyer conspiracy.

For me, "thrust as needed" translates into "apply airmanship here", and all common sense precautions apply, such as when approaching a stall, don't forget to monitor altitude, and don't fly into the ground (which is conveniently repeated multiple times in the FCOM). There is never going to be any one-size-fits-all-aircraft-and-situations-procedure, FAA guidance is biased towards modern large transport jets, and a majority of incidents, and I am sure in some particular situations aggressive increase in thrust will be needed.

Fact remains that for swept-wing aircraft there is generally a tendency to increase AoA when stalled. Stall starts at the trailing edge of the the wingtip, and as it progresses back up the wing, the aerodynamic center is moved forward, raising the AoA. The angle of the aerodynamic force shifts aft, resulting in rise in induced drag, further increaseing AoA (this is nothing new, and there are lots of details in the still excellent "Aerodynamics for Naval Aviators" (http://www.faa.gov/regulations_policies/handbooks_manuals/aviation/media/00-80T-80.pdf)). Since all pilots learned recovery procedures during basic training in a very different aircraft, some may not be fully aware of the characteristics of their current aircraft, particularly in unusual situations. And when they then agressively increase thrust, with the engines below CG, there can be a significant pitch effect, and they may just worsen the AoA problem. Which makes particularly little sense when there is ample altitude available. Getting this information out seems sensible to me.