37.5 degree angle of bank, one engine out, gear down and at 500 feet

[c46r]

Emergency Landing After Bird Strike

On 6 June 2010, a Boeing 737-400 aircraft struck a flock of geese shortly after take off from Schiphol airport in the Netherlands and subsequently completed an emergency landing. The final report on the investigation into the event, has highlighted the importance of adherence to SOPs, bird hazard management, and the need for ATC to pass information about obstacles to aircraft flying below minimum vectoring altitude.
Description

On 6 June 2010, a Boeing 737-400 being operated by Atlas Blue, a wholly owned subsidiary of Royal Air Maroc, on a passenger flight from Amsterdam to Nador, Morocco encountered a flock of geese just after becoming airborne from runway 18L in day VMC close to sunset and lost most of the thrust on the left engine following bird ingestion. A MAYDAY was declared and a minimal single engine climb out was followed by very low level visual manoeuvring not consistently in accordance with ATC radar headings before the aircraft landed back on runway 18R just over 9 minutes later. The aircraft was stopped on the runway where inspection found the right main gear tyres deflated as a result of the high brake unit temperature developed during heavy braking and extensive bird remains in the left main and nose gear bays and in the avionics bay. None of the 162 occupants were injured and the passengers were disembarked using steps brought to the aircraft before being bussed to the terminal.
Investigation

An Investigation was carried out by the Dutch TSB. The FDR and 2 hour CVR recordings were recovered and available to the Investigation. A cross connection in the CVR which had resulted in a 30 minute limit to the CAM channel and a 2 hour limit to the Cabin PA channel instead of the correctly wired opposite was found but was of no consequence to the work of the Investigation.
Extensive damage was found to have been caused internally and externally to the left engine and dents were found in the leading edge of the vertical stabiliser and the lower fuselage. The geese hit, subsequently identified as Canada Geese, were advised as having a mass in summer of between 3 and 5 kg which meant that their weight significantly exceeded the certification requirement for the CFM56-3 engine involved which was to withstand ingestion of a single 1.8 kilogram bird. It was noted that the current enhanced bird ingestion certification criterion for CFM56-sized engines is a single 2.75 kg bird, still less than the mass of those encountered.
It was established that, after a routine reduced thrust take off, the geese had been struck at 16 feet4.877 m above the runway as gear retraction was initiated. A few seconds later, the aircraft commander ordered the First Officer to select the landing gear (which was still in transit) down and declare an emergency to ATC. These actions were taken and radar vectors were requested from ATC. Left engine thrust had immediately reduced to about 45% N1, a negligible amount, and remained at that level until memory actions for engine shutdown were completed approximately four minutes later. The cleared SID had been for a left turn on reaching 500 feet152.4 m agl but, with the landing gear down and a manual reduction in the thrust set on the functioning right engine, rate of climb had been low and at 280 feet85.344 m agl, a turn had been commenced to the right without reference to ATC who had to stop a take off on runway 24 to prevent a conflict. The right turn towards north reached a maximum bank angle of 37.5° and minimum speed of 156 kt288.912 km/h
80.184 m/s IAS, just below the applicable V2 speed, and the aircraft eventually reached a height of just under 500 feet152.4 m agl. From there, a slow descent had begun which only stopped at 352 feet107.29 m following the first of many GPWS activations, in this instance Mode 3 “DON’T SINK”.
Thereafter, the track and altitude flown was persistently erratic and had been accompanied by frequent and sometimes continued GPWS activations as the aircraft passed obstructions or began to descend towards built up areas of Amsterdam. An annotated depiction of the circuit flown is provided in a composite diagram in the Official Report. Height above the ground during the positioning prior to arriving on a final approach to runway 18R varied between 348 feet agl and 629 feet agl. For most of the first four minutes of the flight, prior to the delayed completion of the memory actions for shutdown of the failed left engine, the aircraft was noted to have remained below 500 feet agl.
Throughout, ATC issued radar vectors as requested and the aircraft commander visually avoided obstacles whilst continuing to fly the aircraft manually. ATC had no depiction of terrain or obstacles on their radar and it was noted that the MRVA of 1200 feet365.76 m agl within the Schiphol CTZ. In respect of the issue of radar vectors below MRVA, it was noted that a previous generic review of the risk to persons on the ground had not considered “the risks of advising aircraft in distress below the minimum vectoring altitude, in particular when the visibility becomes outside (the) visual meteorological conditions. In this respect the absence (of) high obstacles on the radar screen increased the imposed risk during the emergency situation. (The ANSP) has no procedure for air traffic controllers that allows for guidance to aircraft in distress in such a situation (and) has not considered the risks of assisting aircraft in distress that are flying below the minimum vectoring altitude in the Schiphol control zone.
The Investigation further found that:
“Air traffic controllers do not know the (exact) location and height of high obstacles in the Schiphol control zone, or cannot know this information because it is not presented on their radar screens. However, controllers do provide headings to aircraft in distress that are flying below minimum vectoring altitude, regardless of the visibility conditions. As a result, aircraft that are flying outside visual meteorological conditions could, if the worst comes to the worst, collide with a high obstacle. In other words, in such a case the ‘assist’ principle would not have contributed to preventing a collision. Although the likelihood of such an emergency is small, the potential consequences are huge, rendering the risk level unacceptable. The fact that crew members do not always follow the instructions and advice provided by air traffic control during an emergency does not diminish this conclusion.”
However, it was concluded that “the threat of this (particular event) for the residents around Schiphol was mainly caused by the crew not observing the ‘initial climb – one engine inoperative’ procedure”.
On the possible value of tactical detection of birds by radar, the Investigation concluded that:
“Further studies should be conducted to assess the operational implementation and applications of radar detection at civil aviation airports. This should also include efforts to identify the responsibilities of the parties involved in radar bird detection, and the extent to which these parties are authorised and at liberty to intervene in flight operations in order to reduce the risk of bird strikes.”
The formal statement of Conclusions of the Investigation was as follows:
Causal Factors
§ Shortly after take-off a bird strike occurred which caused damage to the left engine and reduced thrust to approximately 45%. The flight crew then took the right decision to return to Schiphol airport.
§ However, this decision was not executed in accordance with standard operational procedures. The deviations from the standard operational procedures after an engine failure were:
§ The initiation of a (right) turn at 280 feet with a bank angle of up to 37.5 degrees instead of climbing to the prescribed ‘clean up’ altitude with retracted landing gear.
§ Selecting gear down at very low altitude after it had first been selected up.
§ Reducing the thrust on the undamaged right engine from 94% N1 to 83% N1 instead of selecting maximum thrust.
These deviations from the standard operational procedures resulted in the aircraft only being able to achieve a limited rate of climb, causing it to be unable to achieve the required minimum safe flying altitude. The flight crew had difficulty controlling the aircraft and were distracted by various audio and visual warnings in the cockpit which were the consequence of incorrectly completed cockpit procedures.
Contributing factors
§ During the flight, the crew resource management and crew communication were not in accordance with the international standard for airline pilots.
§ The immediately-initiated right turn and the marginal remaining flying performance made the tasks more difficult and led to complications which meant that both pilots were unable to fulfil their tasks, such as the completion of cockpit procedures and checklist readings, in the prescribed manner. This in turn led to new complications such as unnecessary warnings and an unstable flight path.
§ During the refresher training for Atlas Blue and Royal Air Maroc pilots, they were not trained to deal with multiple malfunctions during the flight.
§ Prior to every recurrent training pilots of Atlas Blue and Royal Air Maroc were taught about the specific malfunctions that would occur. This is not unusual in the context of flight training practice, but the consequence was that the pilots did not learn how to respond to unexpected effects.
§ Dealing with multiple malfunctions featured only in the initial training for Captains.
§ Although the Flight Crew Training Manual and the Flight Crew Operations Manual contain the procedures and checklists required for the adequate tackling of malfunctions which occurred during this flight, the flight crew and the training managers of Atlas Blue and Royal Air Maroc regarded this serious incident as a unique event which pilots cannot be trained in.
§ The analysis of measures implemented in response to the (third party risk) investigation (initiated in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry) failed to take account of the risks caused by aircraft in distress situations flying below the minimum vectoring altitude. These aircraft are given headings in the Schiphol Control Zone, despite the fact that air traffic controllers do not have information on high obstacles in the flight path. This unnecessarily increases the risk of a collision. This problem is all the more urgent when aircraft are flying outside visual meteorological conditions.
§ The investigation conducted by (ANSP) Air Traffic Control the Netherlands in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry has resulted in a policy framework on the supervision of aircraft in distress situations and on flying over densely populated areas. According to this policy framework for aircraft in distress situations, the captain is responsible for flight operation while the air traffic controller provides assistance to the cockpit crew. Aircraft in distress must use existing runway arrival and departure routes where possible, which limits the amount of flying over densely populated areas. The Directorate-General of Aviation and Maritime Affairs has approved the aforementioned policy framework. As a result of this policy framework, densely populated areas are not presented on air traffic controllers’ radar screens.
§ Schiphol airport is practically surrounded by a great number of populated/built-up areas. The consequences of flying lower than the minimum vectoring altitude are (considerable). This is particularly the case when flying outside visual meteorological conditions.
§ The maximum height above the ground of the aircraft during the flight was 730 feet and this was well under the minimum vectoring altitude for Schiphol of 1200 feet.
§ Only two obstacles are displayed on the radar screen, of which one is in the Schiphol control zone (whereas) there are a number of other obstacles which might pose a risk to aircraft flying lower than the minimum vectoring altitude. This is particularly the case when flying outside visual meteorological conditions.
§ The presence of one or more birds with a large total mass in the flight path of an aircraft is a risk to flight safety. This particularly applies to geese due to their considerable mass and because they fly in groups. Most bird strikes occur during the take-off and landing phases of the flight.
§ The Investigation has shown that parties that have a direct influence on bird control at Schiphol airport have exhausted their options. Except for the closing of active runways more often, it is up to other parties, therefore, to take further measures to reduce the safety risk caused by bird strikes.
§ All the aviation, agricultural, and bird and environmental protection parties acknowledge the bird strike risk as such and the need to reduce this risk. Although the parties agree on the necessary measures, there is no such consensus with regard to their effect. As a result, there are also differing views as to the (cost-)effective implementation of these measures.
§ Due to the high level of urgency involved, there is no time to wait for the outcome of ongoing pilots to assess alternative control measures that would yield results in the longer term. The reduction of goose populations represents the most effective short-term measure. In the longer term, habitat management and improvement of the measures to detect and scare off birds could also help structurally reduce the risk of bird strikes.
§ Seven civil-society organisations united in the “Goose 7” recently prepared a joint national and regional recommendation, outlining measures to reduce and stabilise the population of various types of geese in the Netherlands at a certain level. The implementation of this recommendation as a short-term measure will require the approval of the State Secretary of Economic Affairs, Agriculture and Innovation, which approval thus far has not been forthcoming.
§ The Ministry of Infrastructure and the Environment, responsible for aviation safety, has not sufficiently coordinated measures aimed at reducing the risk of bird strikes.
Seven Safety Recommendations were made as a result of the Investigation:
§ That Royal Air Maroc demonstrate to the Moroccan Ministry of Transport that:
§ the procedures for communication and crew resource management between crew members have been harmonised with the international standard for airline pilots.
§ pilot training has been expanded to include simulations of multiple unexpected failures.
§ That Air Traffic Control the Netherlands and the Minister of Infrastructure and the Environment:
§ ensure that aircraft in distress flying under the minimum vectoring altitude are informed about high obstacles in the Schiphol Control Zone.
§ That the Minister of Infrastructure and the Environment, responsible for aviation safety:
§ take(s) proactive measures to ensure the minimisation of bird strike risks.
§ with the greatest possible urgency and vigour implement effective measures to reduce and stabilise the population of various goose types in the Netherlands at a certain level in accordance with the “Goose 7” recommendation in order to reduce the risk of bird strikes.
§ Ensure(s) that the interests of aviation safety are safeguarded within the various relevant policy domains, by preparing enforceable emergency measures that allow for intervention if the risk of bird strikes becomes too great.
§ Conduct(s) studies to assess the potential of technical measures to reduce the risk of bird strikes.
The Investigation was completed on 29 November 2011 and the Final Report: Emergency landing after bird strike, B734, Amsterdam Schiphol Airport, 6 June 2010 released.

[thepotato232]

I think I need a new pair of trousers just reading that...

[Agaricus bisporus]

Gear up at 16 feet? Gear down again immediately after a birdstrike? Reduced power on the good engine? Kinda sets the scene for the horlicks that comes next, does't it?

What a shambles.

Perhaps it will take 250 bodies and a half mile hole in central Amsterdam to make the Ministry of Agricultural Obfuscation get the shotguns out and start to cull the swarms of those horrible creatures. Canada geese near airfields are a lethal hazard. My God, will we ever learn?

[Momoe]

Bird strikes happen and will continue to do so as long as birds and planes continue to fly; deterring birds near flight paths may reduce the incidence but the issue here is what went on in the cockpit, not outside.

[Clandestino]

So that's what Bill Voss meant when he said "This is not about better stick and rudder skills".

Page 17 of the report is... impressive, to say the least.

EDIT: found the original thread. (http://www.pprune.org/rumours-news/417381-emergency-landing-air-maroc-eham-june-6th.html)

[chimbu warrior]

the flight crew and the training managers of Atlas Blue and Royal Air Maroc regarded this serious incident as a unique event which pilots cannot be trained in.

This statement worries me, and more than a little. What do you think Centaurus?

[BOAC]

I would suggest that telling crews that putting the gear down and reducing power on the 'good' engine to just above cruise N1 might NOT be a good idea?

Edit: just noticed NOT had fallen on the floor:)

[oceancrosser]

Any link to the report itself?

[BOAC]

Post #5 perchance?

[TWT]

http://www.skybrary.aero/bookshelf/books/1762.pdf

[Jet Jockey A4]

Lucky to be alive!

[TonyDavis]

I was under the impression that basic simulator training concentrates a large period of time in dealing with engine failures before and after V1 and EFATO training inline with the aircraft certification.

I was also under the impression that EFATO procedures are to select gear up and be at v2 or v2 + 10 at 35 feet. Then continue to climb to a minimum of 400 feet agl, straight ahead (unless an emergency turn is stated fro the runway in use) (in other words ignore the SID). At 400 feet or higher (800 for most operators) level acceleration for flap retraction, and attain best angle of climb speed,then select MCP and continue to 1500 feet AAL. Then manouever. This will keep the aircraft in the SPLAY and guarantee at least 35 feet obstacle clearance (nett flight path).

It has been my experience that a lot of pilots are poorly trained in this procedure and new pilots not trained in the theory.

[aterpster]

Momoe:

Bird strikes happen and will continue to do so as long as birds and planes continue to fly; deterring birds near flight paths may reduce the incidence but the issue here is what went on in the cockpit, not outside.

Absolutely! This should have been a non-event.

[aterpster]

The analysis of measures implemented in response to the (third party risk) investigation (initiated in response to the recommendation by the Bijlmermeer Air Disaster Parliamentary Board of Inquiry) failed to take account of the risks caused by aircraft in distress situations flying below the minimum vectoring altitude. These aircraft are given headings in the Schiphol Control Zone, despite the fact that air traffic controllers do not have information on high obstacles in the flight path. This unnecessarily increases the risk of a collision. This problem is all the more urgent when aircraft are flying outside visual meteorological conditions.

This statement is almost as chilling as the incident itself. It implies a complete lack of understanding of OEI flight paths and procedures.

[misd-agin]

That answers a trivia question that guys re-invent over and over again - how well does the plane climb single engine with the gear down and/or less than T.O. power?

Not very well or maybe not at all.

[hetfield]

Was it a test-flight?

[before landing check list]

I have no idea why or see any reason why the gear should be lowered while flying with an engine out and not being in position to land somewhere. Can anyone here? What happened climbing to the prescribed ‘clean up’ altitude with retracted landing gear then sorting the rest out? I think it was a poorly trained crew who is in dire need of getting back to the basic of flight 101.

[TonyDavis]

I completely agree with before landing checlist. It appears that here is yet another badly trained crew, the same as AF, who have not been trained in basic procedures. From what I have seen of the training industry and learning by rote there is going to be more and more of this.

It worries me that the Dutch Authority is even looking at what happened after the aircraft left the splay. It was pure luck that it did not hit something. The area around Schipol is flat as a pancake, most other airports and the aircraft would have hit something.

[PURPLE PITOT]

I haven't read the report, but is it possible that the captain, having determined that they had taken gear damage from the strike, used an old jedi trick that we used to call airmanship, and put the dunlops back down before they uplocked?

[wiggy]

I was also under the impression that EFATO procedures are to select gear up and be at v2 or v2 + 10 at 35 feet. Then continue to climb to a minimum of 400 feet agl, straight ahead (unless an emergency turn is stated fro the runway in use) (in other words ignore the SID). At 400 feet or higher (800 for most operators) level acceleration for flap retraction, and attain best angle of climb speed,then select MCP and continue to 1500 feet AAL. Then manouever. This will keep the aircraft in the SPLAY and guarantee at least 35 feet obstacle clearance (nett flight path).

It has been my experience that a lot of pilots are poorly trained in this procedure and new pilots not trained in the theory.

Is that a 737 procedure only Tony? I only ask because it's certainly not the approved manner of handling engine failures on some other types, and in any event ignoring the SID could bring you a world of pain departing many airports.

Mind you I don't think the guys in the Amsterdam near accident were using any recognised procedure.....:eek:

[DOVES]

The right turn towards north reached a maximum bank angle of 37.5° and minimum speed of 156 kt288.912 km/h 80.184 m/s IAS, just below the applicable V2 speed, and the aircraft eventually reached a height of just under 500 feet152.4 m agl. From there, a slow descent had begun which only stopped at 352 feet107.29 m following the first of many GPWS activations, in this instance Mode 3 “DON’T SINK”. You all teach me that V2 = equal or more than 1,1 VMCA and 1,2 Vs. With such a bank Vs increment is 14%, so they were only: 0,2 – 0,14 = 1,06 Vs. We all know that a swept wing stalls at the end first generating a strong pitch up moment, and with the asymmetric thrust they had, God only knows why they didn’t get into a spin. § During the refresher training for Atlas Blue and Royal Air Maroc pilots, they were not trained to deal with multiple (??? MERE “ENG. FAIL!!!”)malfunctions during the flight.
§ Prior to every recurrent training pilots of Atlas Blue and Royal Air Maroc were taught about the specific malfunctions that would occur. This is not unusual in the context of flight training practice, but the consequence was that the pilots did not learn how to respond to unexpected effects (WHAT???).
§ Dealing with multiple malfunctions featured only in the initial training for Captains.
In my aviation career I’ve been trained/checked (and I did it to my students) at least 40 x 3 = 120 times, and in IMC, and from airports like Zurich, not a plateau like Schiphol airport, in many aicraft types simulators.
Shame on those responsible.
Fly Safe
DOVES

[aterpster]

P.P.

I haven't read the report, but is it possible that the captain, having determined that they had taken gear damage from the strike, used an old jedi trick that we used to call airmanship, and put the dunlops back down before they uplocked?

You only deal with such possibilites one you have completed the OEI profile and have sufficient altitude and speed to consider returning to land. Perhaps they need to dump fuel first. (?)

[Dawdler]

Despite all the criticism of the captain and the listing of his failings, one cannot fault the fact that he got the aircraft back on the ground with all onboard intact. Even if it was at some inconvenience to others, I suspect his prime aim was to achieve a landing.

[tbaylx]

It sure as heck isn't good airmanship to lower the gear on an engine failure after t/o.

"well we hit that hill off the end of the runway cause we couldn't maintain second segment climb, but at least we had the gear down"

I'd rather meet my climb gradients with the gear stuck up and do a controlled landing gear up on the runway then hit an obstacle on climb out. Nothing in that report suggested good airmanship or decision making skills, in fact the exact opposite.

A routine failure that crews should be able to handle as a non event (see thomson bird strike at about the same spot for an example of how a professional crew might handle this) came very close to becoming a fatal accident..again due to poor crew training and or abilities. ThomsonFly 757 bird strike & flames captured on video - YouTube

A v1 cut is one of the most basic maneuvers trained in the sim, yet this crew was unable to complete it in a safe manner. The only reason this ended well is luck. If you think otherwise, next time you're doing a v1 cut in the sim, try reducing the thrust on the good engine, lowering your previously retracted gear and commencing a 30+ degree banked turn below 400' on departure and let me know what your instructor has to say about your good airmanship and decision making.

[Mikehotel152]

Based on that report, what a shocking lack of airmanship! :eek:

Climb straight ahead, get away from the cows. This low level cropspraying behaviour in a built up area is nuts.

[hetfield]

I haven't read the report, but is it possible that the captain, having determined that they had taken gear damage from the strike, used an old jedi trick that we used to call airmanship, and put the dunlops back down before they uplocked?

Maybe, but I wouldn't call that airmanship to reverse a travelling gear.

[Momoe]

Dawdler, captain's prime aim ain't in doubt, however his actions to achieve said aim were way off the accepted mark and leaving the gear down was incomprehensible.

Purple pitot - free thinking has it's place but reducing power on the good donk!!!!!!
The guy wasn't thinking straight and somehow got away with it, the only concession I'll give you is that he did have some piloting ability which is what got the plane back in spite of his pi$$ poor decision making.

Nice whitewash by Royal Air Maroc BTW

[TonyDavis]

Wiggy

Is that a 737 procedure only Tony? I only ask because it's certainly not the approved manner of handling engine failures on some other types, and in any event ignoring the SID could bring you a world of pain departing many airports.

It certainly is on the types that I have flown for real and in the simulator (B727,B737,B747,B767 BAC 1-11 and L1011). All the old performance A. Type A and Type B ICAO airport charts only accurately survey the splay and or designated emergency turn. If you look at any of the SID's for LHR you will see a minimum reqd climb gradient of around 800 fpm. Any transport aircraft at max regulated take off weight will probably not achieve anyway near that with an EFATO.

The Max regulated take off wieght is computed assuming you are going to carry out the procedure that you are trained to do. If you listen to the Thompson video you will hear that they went to Wallasea on an assigned heading which is designated in the emergency turn for Manchester, not the SID. ATC will expect you to carry out your procedure once the mayday call is made.

There is a great publication from Airbus called Getting to Grips with Performance. Its good reading, revision for all pilots.

[tbaylx]

That's the procedure in most airline ops that i am familiar with, certainly on the Boeing's. If it's flown like Tony has stated you will clear obstacles on the flight path. If there are obstacles that you would not clear then there will be an emergency turn specified in the event of an engine failure that the crew would need to comply with.

The only difference from Tony's explanation that i have seen is the turn is complied with prior to accelerating the aircraft to single engine climb speed.

[fireflybob]

One of the challenges facing modern aviation is that (mechanically speaking) things rarely fail.

Remember reading an article decades ago by an airline pilot who had grown up on aircraft such as StratoCruisers and Constellations crossing the pond. He then converted to the Boeing 707. After he had flown the B707 for circa 7 years he looked back though his logbook and realised that on said a/c he had never had an engine shutdown or any type of failure/fire etc. He went on to say that in his previous types on an atlantic crossing it was very rare not to encounter some form of engine problem (large piston engines with lots of reciprocating parts versus jets).

On older a/c with less reliable powerplants the crews routinely expected to encounter an engine malfunction and were therefore more "geared up" (sorry about the pun!) for a failure.

These days most crews hardly ever experience a real engine malfunction other than in the simulator. Throw in a bit of the "magenta line" culture and we have a potential recipe for disaster. This means that crews have to be even more disciplined and mentally alert for the events such as these. This in turn also means crews must be better trained in all respects.

It was purely fortuitous, I would suggest, that this was an incident and not a major accident - a very lucky escape.

[PURPLE PITOT]

Ok, i have now read the report. In all probability these guys were muppets. I still stand by my view point, and fail to understand why others do not, that sometimes you may need to think for yourself.

[wiggy]

Tony

I would be interested to know what Type you are flying?

Currently 777, before that the 747, mostly the -400...........European operator, over 15000 hours, mostly on the 744.

..I understand the assumptions that are made in order to produce the performance calculations, and the EFATO procedure you described, containing the level acceleration, rings bells of my EFATO training on the Classic 747 many years ago. My minor gripe with your OP was that Boeing's FCOM 1 for the likes of the 744 and the 777 describe a subtly different profile and demand a different procedure ( e.g. it's a climbing acceleration, there should be no need to make an MCP speed selection to increase the angle of climb ...), so I felt your seemingly blanket comment that:

It has been my experience that a lot of pilots are poorly trained in this procedure was somewhat harsh.

That said I'm sure we're singing from the same hymn sheet in our thoughts about this incident :eek:

[TonyDavis]

I understand that on some types you can afford a slight climb on the third segment. The selection of MCT at the end of the third segment is making the asumption that thrust above MCT was used at the start of the take off. The 10 minute power limitation comes in to play (used to be 5 minutes). MCT must be set at the 10 minute period and the end of the third segment must be complete (ie flap retraction). This was the major reason for a flat segment to make sure you dont exceed the power limitation with flap still out.

[golfyankeesierra]

For report see this link (http://www.onderzoeksraad.nl/docs/rapporten/Rapport_Royal_Air_Maroc_EN_aangepast_web_10012012.pdf)

Pictures say more then words, take a look at page 17 (can't post the image).

[Denti]

I note that the Captain was a TRI. Unbelievable

Sadly, not really... Having encountered enough TRIs that went to a jet with 180 hours, to the left seat with 2000 hours and became TRIs with 2200 hours and never really learned to fly along the way. And yes, in the middle of europe, not china or north africa.

[TonyDavis]

I stand by my comment regarding poor training and knowledge. As an MCC instructor I would say that only 5% of the students had any idea of EFATO procedures on jet transports note that this training is not part of an MCC course. Most of these 250 hour FATPL students were hoping to get a jet transport job as soon as they had completed the course. The last hole in the cheese is that the airline trains them properly. In this case RAM did not.

It seems the answer is to slaughter all the Canada geese. I would have thought it better to close down the airport.

[Denti]

that this training is not part of an MCC course Really? Things must have changed then. Apparently not for the better...

[Clandestino]

The idea behind giving the commander the authority to deviate from established rules and procedures is to achieve higher level of safety through breaching them, not lower.

IMHO, this fellow was very near to getting totally overwhelmed by having the real emergency thrown on him and that's something that cannot be corrected by additional training. There should be psychological selection even before basic training is commenced, not quite dissimilar from:

Separation of the dedicated from the merely hopeful has been a crafty affair performed mostly by the line's chief pilots. They are braced with a fixed set of standards from which, in self-protection, they rarely deviate. They are hard, suspicious men, navigating uncomfortably between what is a frankly commercial enterprise and a group of fractious, often temperamental, zealots. And since it is also their lot to be the first to inform a pilot's wife that she is now a widow, they do what they can to see within an applicant. They try to picture him a few years hence, when he may find himself beset with the troubles aloft. How will he behave in sole command, when a quick decision or even a sudden movement can make a difference between safety and tragedy? Yet the chief pilots do not look for heroes. They much prefer a certain intangible stability, which in moments of crisis is often found among the more irascible and reckless.

Of course, we have come a long way from 1930ies, so such an approach might not serve well our enlightened age. Besides, harder selection would be bad for flight training industry and its collapse could adversely affect the airlines. We don't want that to happen, do we? :E

[Arkroyal]

Hmmm...

Interesting moderating.

Why have my and Purple Pitot's posts been removed?

No abuse, no rule breaking.............

[lomapaseo]

golfyankeesierra

For report see this link (http://www.onderzoeksraad.nl/docs/rapporten/Rapport_Royal_Air_Maroc_EN_aangepast_web_10012012.pdf)

Pictures say more then words, take a look at page 17 (can't post the image).

Is this the image?

http://fromtheflightdeck.com/MEL/PPRune/Page%2017.jpg

[Jet Jockey A4]

I don't know whether to laugh or cry.

All I know there are some lucky folks onboard that aircraft. They sure came close to a disaster on that flight.

Why did they not just follow the SID, clean up the aircraft on schedule and perform the required check list at a safe altitude all according to company SOPs?

IMHO this was a very poorly executed engine failure/emergency procedure and the crew should be reprimanded for it.

[Big Pistons Forever]

. I still stand by my view point, and fail to understand why others do not, that sometimes you may need to think for yourself.

Could you explain how "thinking for yourself" could have produced a better result for this exact set of circumstances then following the Boeing SOP for an engine failure after V1 ?

From what I could see there was nothing especially unusual about this case. Yes the engine failed in a nasty place but from my POV simply following the "book" actions would have caused the the aircraft to climb to safe height after which a routine single engine landing would have been prepared for and executed.

What am I missing ?

[kick the tires]

PP

I haven't read the report, but is it possible that the captain, having determined that they had taken gear damage from the strike, used an old jedi trick that we used to call airmanship, and put the dunlops back down before they uplocked?

and interupt the gear up sequence? Not something I would be comfortable with. I'm no mechanic or specialist in the working of undercarriage but I wouldnt of thought that changing gear up sequence to a gear down one would do the dangly bits much good.

[Capn Bloggs]

We all know that a swept wing stalls at the end first generating a strong pitch up moment
I don't think so.

[FullWings]

From what I could see there was nothing especially unusual about this case.
Yup.
Yes the engine failed in a nasty place...
Mind you, a V1 cut is what is practiced the most. I wonder what the result would have been if it had happened at 200', 15-20deg NU or during the clean up?
...simply following the "book" actions would have caused the the aircraft to climb to safe height after which a routine single engine landing would have been prepared for and executed.
Does look that way. I haven't been able to view the report yet but judging from the flight profile on the chart, it would appear that not much in the way of automation was used to try and lower the workload.

Also from the chart, if they were that desperate to get on the ground, they were lined up with 36C then 36L shortly after. Doesn't really make sense. :confused:

[stilton]

I just think C46r should learn what a paragraph is.

[Heathrow Harry]

What surprises me is that ATC at one of the worlds best and major airports have no way of calling up an overlay with major obstructions on it on their screens

I'm sure we have that at LHR ... don't we???

Tough to be too hard on the Captain - massive bird strike at 16ft - and he got everyone back in one piece

[HeadingSouth]

Dutch irony is that the report shows a low flying aircraft over inhabited areas on the top of the very front page :D ?? :E

[Roger Greendeck]

I don't see why its being tough on the captain to be highly critical of his actions. We often point out that as captain choosing a course of action is up to us. The corolary of this is that we are responsible for our actions and should be fully willing to accept criticism for poor choices.

In this instance there is no indication of having to choose the lesser of two evils. There is a simple and effective procedure for this very event that is practiced regularly in the sim and, in any reputable organisation operating these types of aircraft, is briefed just prior to taking off.

Whilst it is true to say that he got the aircraft on the ground and so at one level is could be considered a success the investigation has not found anything that indicates the normal procedure would not have worked and plenty of evidence that the crew did many things to reduce the chance of a successful recovery. That the company is reported to consider this '... a unique event which pilots cannot be trained for' beggars belief and is, I suggest a root cause of the problem than one pilots poor choices on the day.

[Ornis]

Gear down, tight turn. Was he thinking 36C or L?

[Centaurus]

Quote:
the flight crew and the training managers of Atlas Blue and Royal Air Maroc regarded this serious incident as a unique event which pilots cannot be trained in.
This statement worries me, and more than a little. What do you think Centaurus?

From reading the full report it is clear that the captain stuffed up badly. Also the first officer blindly lowered the landing gear when the captain called for it shortly after it had been retracted. One would have thought it would have been obvious to the F/O this was a seriously bad call by the captain in-flight performance-wise and at such low altitude. He should have told the captain this but he didn't.

There was mention in the report that the crew (presumably the F/O) was engaged in "programming the computer" as the aircraft was flogging around at low level just above the built up area and within four miles of the airport. The Children of the Magenta Line syndrome comes to mind. There was no need to play with the computer unless the crew were not up to quickly selecting basic navaids for the airport.

The experience of the crew was interesting. The captain had only 340 total flying hours when he first flew the 737 and the F/O had a mere 430 hours before going on to the 737. From then on the remainder of their flying hours was on the 737. Draw your own conclusions. In other words no sound past command decision making experience to fall back on.

From reading the incident report it is clear the captain was well out of his depth. All the simulator training in the world does not necessarily make a good pilot able to cope with the unexpected. Some pilots have cool heads while others instinctively rush things. It is a human factors trait that can only be partially addressed by simulator training. He had a straight forward engine severe damage shortly after lift off.

If he had stuck to FCTM SOP and not rushed things it would have been a normal single engine landing with Flap 15. Instead panic set in and the rest is covered in the report. Lowering the landing gear shortly after the gear had been selected up and on a single engine climb is an example of blind panic without first considering the effect on climb performance. Power reduction on the remaining engine was made probably without noticing what N1 he had.

[aterpster]

Heathrow Harry:

What surprises me is that ATC at one of the worlds best and major airports have no way of calling up an overlay with major obstructions on it on their screens

I'm sure we have that at LHR ... don't we???

That is a question for the staff at Heathrow. :)

In the U.S. almost all of our TRACONS have an Emergency Obstruction Video Map (EOVM), which they can call up very quickly if need be. I have linked a PDF file for KLAX. The first page is a portion of the MVA video map, the second page is the same area, but with the EOVM video map.

The EOVM provides only 300 feet of vertical clearance.

Index of /LAX (http://WWW.TERPS.COM/LAX/)

[macdo]

Two more airlines I won't be positioning with then. Bunch of criminally negligent muppets who only avoided disaster by chance. Appalling incident.

[DOVES]

Were they trained by same instructor and training facility as those of:
Turkish Airlines Flight 1951 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Turkish_Airlines_Flight_1951?)

I think someone has to rethink programs and structure.
What???
The experience of the crew was interesting. The captain had only 340 total flying hours when he first flew the 737 and the F/O had a mere 430 hours before going on to the 737.
I've alway believed that to couple a Captain and a co-pilot having both so little experience is forbidden!
PurplePitot
You know very well that if you abandon the SOPs you venture into an uncharted minefield, the consequences of which you take and impose upon those who sit beside you, and your passengers.
There are cases, in addition to that of the heroic Sully, the United Airlines 232 flight of July 19, 1989, the El Al Flight 1862 of October 4 1992, the SWISSAIR flight 111 of September 2 1998, the AIR FRANCE flight 4590 of July 25, 2000, etc. when the Captain is forced to exercise his emergency authority, and deviate from the published procedures (also because perhaps he is experiencing an unforeseen situation) in order to save his crew and his passengers.
But I wish you never find yourself in a similar situation.

[BOAC]

Hey y'all - The captain had only 340 total flying hours when he first flew the 737 and the F/O had a mere 430 hours before going on to the 737. From then on the remainder of their flying hours was on the 737. Draw your own conclusions. In other words no sound past command decision making experience to fall back on. - as presented, this is MEANINGLESS. PLEASE do not get hung up on this quote and produce pages of nonsense:ugh:

[DOVES]

Originally Posted by Doves
We all know that a swept wing stalls at the end first generating a strong pitch up moment

Capn Bloggs:
I don't think so. Pitch-up - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Pitch-up)
Deep Stall. (http://xoomer.virgilio.it/paolopoggiolini/SuSt/SuStEn.htm)

I know You knew.
You were testing me! Weren't You??!!

[ap08]

The correct way to deal with this incident would be to ban the company from ever entering European airspace again. Unfortunately this is not going to happen :(

[Bigmouth]

Perhaps it will take 250 bodies and a half mile hole in central Amsterdam to make the Ministry of Agricultural Obfuscation get the shotguns out and start to cull the swarms of those horrible creatures. Canada geese near airfields are a lethal hazard. My God, will we ever learn?

Up until the second to last sentence (... those horrible creatures) I honestly thought you were talking about the pilots.
And though I didn´t really want to say it out loud, I wash´t disagreeing.

[cwatters]

Any web cams on the KPN tower?

[mini]

I've never flown anything bigger than a Rallye 150... but reading this thread makes me feel I've a future in long haul.

Deciphered... What a cluster f**k,

There can be no excuses for the actions carried out during this event.

The big question I have is who certified these guys?

What (alleged) standards has this certifying authority?

Murder waiting to happen IMHO,

Piss poor recruitment and training regimes, i.e "Daddy" has sorted my income?

[The Ancient Geek]

Also from the chart, if they were that desperate to get on the ground, they were lined up with 36C then 36L shortly after. Doesn't really make sense.


My best guess is that this is what they tried to do but the chosen runway(s) were not available so they flew a short pattern to line up for the next available.
AMS can get hectic at times.

This was not a simple engine failure, the aircraft collided with a flock of heavy geese which implies a stong possibility of other damage. In the circumstances a desire to get back to terra firma ASAP is understandable.

Not the way I would have done it but it is easy to criticise, none of us were there.

[lomapaseo]

Ancient

No argument with the tone of your post but just a nit

This was not a simple engine failure, the aircraft collided with a flock of heavy geese which implies a stong possibility of other damage. In the circumstances a desire to get back to terra firma ASAP is understandable.



I had also asked myself the same question but in the end I concluded that the crew's action was probably only based on their instruments, overt symptoms, and fidelity of their training

It was only during the investigation afterwards that larger birds than certified for or other damage was noted

I hold nothing as yet against the crew but I suspect that that airline is in for a rough time on future flights into European airports until they meet standards

[kinteafrokunta]

You guys weren't there! You did not know what went through the captain's mind then...he must have had flash backs to the scenes of Sully's Hudson river ditching with the possibility of losing both engines. There was a possibility that he was thinking of a quick 180 turn, leaving the gears and flaps in place looking for some concrete to land the crippled plane. He was probably weighing all his options as well and handling the crippled plane with all the cockpit warnings and erratic indications. All you insufferable arm chair critics and Monday morning quarter backs should have a chill pill up your sixes.

[aterpster]

You guys weren't there! You did not know what went through the captain's mind then...he must have had flash backs to the scenes of Sully's Hudson river ditching with the possibility of losing both engines. There was a possibility that he was thinking of a quick 180 turn, leaving the gears and flaps in place looking for some concrete to land the crippled plane. He was probably weighing all his options as well and handling the crippled plane with all the cockpit warnings and erratic indications. All you insufferable arm chair critics and Monday morning quarter backs should have a chill pill up your sixes.

Thanks for that great assessment Mr. Troll.

[FlightPathOBN]

One has to understand what the criteria standards are for obstacle and terrain eval. When ATC states they dont have the obstacle data, they are in actuality right on.
Terrain and obstacle surfaces are evaluated, and the CONTROLLING obstacle per sector is reported, not all, only the highest one. Obstacle evals are done on a 5 year basis, and most are beyond that, so any construction in the last 5 years, will only show up IF it is the new control.
Obstacles shown on charts are for information only, as in, you are on approach, and there is a building or mountain close on final, you understand that yes, this was accounted for...
In most places, there is NO mandatory requirement, that the person is able to ascertain, to submit the construction to the FAA or relevant authority, as part of the construction permitting.

[Escape Velocity]

You guys weren't there! You did not know what went through the captain's mind then...he must have had flash backs to the scenes of Sully's Hudson river ditching with the possibility of losing both engines. There was a possibility that he was thinking of a quick 180 turn, leaving the gears and flaps in place looking for some concrete to land the crippled plane.You have (inadvertently) nailed the basic reason for this totally mis-handled event.

He was probably weighing all his options as well and handling the crippled plane with all the cockpit warnings and erratic indications. All you insufferable arm chair critics and Monday morning quarter backs should have a chill pill up your sixes. Unfortunately, you have drawn the wrong conclusions. At a minimum both crewmembers panicked and came extremely close to stuffing the airplane into a crowded neighborhood. At worst, one or both suffered from what I call the "Sully Syndrome".

I have seen an alarming increase over the last two years of the Hudson River ditching being used in training cycles. It is popping up as a shining example for CRM classes (dubious), has caused a new-found love for esoteric and useless systems debates (I walk away from these) but thankfully I have not seen it invade the simulator (hopefully it never does, either officially or unofficially).

I am not in any way trying to tarnish the performance or image of Capt. Sullenberger and crew, but face it, there is little useful information to be learned from that event except that when faced with a double flameout over a big city, look for the softest spot to land, and by the way, you don't have a lot of time to make up your mind. The Hudson River ditching has, however, created one of those nasty little unintended consequences: the Hero Captain has re-emerged! I can save us all, just let me get my hands on those controls!! Screw the checklist, I know better!!

What the Atlas Blue crew had was a routine bird strike after liftoff followed by the left engine rolling back with unknown damage. That's it. Nothing more. We all train for and practice this every six months. There is even a checklist in the QRH for this very event, plus a couple of memory items that are supposed to go with it. A TSB report and (so far) a 4-page discussion of this incident exists for one reason only: Hero Captain Syndrome.

I used to teach that the first memory item on any emergency checklist was "fly the airplane", followed closely by "take a deep breath" then "wait", then "Memory Items". "Don't panic", "don't be a hero" and "don't do anything stupid" were implied. Maybe not (sigh).

[clevlandHD]

DOVES,

on every airliner with swept wing (707 onward), the wing is twisted to mitigate the problem of wingtip stall. Modern wings will stall at the root first. Instead of wiki, you should read "Handling the Big Jets".
As for Deep Stall, it is a T-tail problem.

[henra]

Originally Posted by Doves

Capn Bloggs:
Pitch-up - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Pitch-up)
Deep Stall. (http://xoomer.virgilio.it/paolopoggiolini/SuSt/SuStEn.htm)



I hope this is not the source you take your aviation knowledge from.
Although it is not completely false you might want to check if what is written there applies to a modern conventional airliner post 1960's.

The MiG 15 purportedly showed such behaviour mentioned in the Wiki article. Quite a number was said to be lost for that reason over Korea.

However, as @clevland has mentioned time has moved on and the designers have taken steps to mitigate this problem. Twist and taper/ relative chord thickness will take care of it.

Empirically swept wing airliners which have stalled showed rather a mush- down behaviour (see also AF447) when applying lots of Nose up Trim to prevent the nose from dropping.
(There have been only very few cases of an airliner stall without siginifcant Nose- Up trim, the high Altitude stall/spin of a Tu-154 when trying to climb above a TS over Russia being the odd exception but that was a T- Tail)

Deep stall is a phenomenon that in its proper sense only exists in T- Tails.
In conventional tails you can simulate somewhat similar effects with violent Nose Up trim + Elevator.

There are no documented cases of a conventional tail airliner pitching Nose Up due to stall with a neutral trim and elevator.

[golfyankeesierra]

golfyankeesierra

Quote:
For report see this link

Pictures say more then words, take a look at page 17 (can't post the image).
Is this the image?
lomapaseo, yes, thanks.
That must have been some unbelievable stress for crew and pax in the first few rows with that noise coming out of the cockpit!

[Ornis]

If the commander turned back with the intention of landing on a reciprocal vector, comprehensible if wrong, but found he couldn't, why wouldn't he raise the gear (and increase thrust)? It just seems so basic. Is he is still flying?

[LeftHeadingNorth]

@Escape Velocity, A very sound post indeed. Is is amazing how a not so devastating event turned into major event...

I used to teach that the first memory item on any emergency checklist was "fly the airplane", followed closely by "take a deep breath" then "wait", then "Memory Items". "Don't panic", "don't be a hero" and "don't do anything stupid" were implied. Maybe not (sigh).

I wonder how many lives would have been saved had pilots done just that.... :suspect:

[sheppey]

Quote:
The captain had only 340 total flying hours when he first flew the 737 and the F/O had a mere 430 hours before going on to the 737. From then on the remainder of their flying hours was on the 737. Draw your own conclusions. In other words no sound past command decision making experience to fall back on.
- as presented, this is MEANINGLESS. PLEASE do not get hung up on this quote and produce pages of nonsense:ugh:

Disagree. Others would argue the suggestion of very low flying experience of basic CPL before going on to the 737 had a lot to do with the rushed behaviour of the captain that very nearly turned into disaster. Many airlines would never remotely consider hiring a pilot with less than 2000 hours unless military trained. The captain in this incident would have had only PPL and CPL command hours ie no serious command on anything except perhaps a light single and light twin while under training for his CPL. Then he hops into the RH seat of a 737 at 300 plus total hours. Not exactly the highly experienced second in command of a passenger jet the passengers would hope to have. This is the inherent risk factor endemic in many airlines now and although statistics will no doubt prove it is cost-effective, it fails to disguise the fact that captains saddled with low hour CPL first officers better not become incapacitated leaving the cadet to fly single handed.

Like the captain, the F/O in the discussion also started off with barely the CPL in the RH seat of a jet. In other words no serious decision making time with which to fall back on. His whole career so far was as a subordinate taking instructions. This showed in his failure to prevent the captain making a series of seriously poor handling decisions.

[aterpster]

FlightPathOBN:

In most places, there is NO mandatory requirement, that the person is able to ascertain, to submit the construction to the FAA or relevant authority, as part of the construction permitting.

In the U.S. what about FAR Part 77?

[TonyDavis]

Very good post Sheppey.

I would suggest that the Dutch investigator has missed a golden opportunity here. Instead of concetrating on how to slaughter the geese, once they had determined that these 2 did not folow a basic procedure, they should have dug a lot deeper by questioning the crew on their knowledge of take-off procedures and the reasons we have them instead of Oh that was question 26 and the answer is A.

The PM should have been doing his job, which primarily is MONITORING. If PM does not know what should be happening then how can he monitor?

This is the problem of having 250 hour guys in the RHS unless they are very well trained. Even AF failed in this. This is not a new problem. Air Florida at Washington was another classic example of 2 pilots not knowing what was going on through lack of training. I remember the reams of paper coming out from Boeing and PW regarding EPR indications and the need to back it up with N1 and FF indications.

The training industry is presently geared up to spew out as many pilots as possible at the lowest price, hoping that the airlines will rectify the lack of knowledge. The regulators have also not helped by using multi choice to save money and then making the question database available to the schools for Rote learning. Also RAM is one of the airlines offering cheap type ratings.

Here was a golden opportunity for the Authority to really find out what is going on. However due to cost cutting is there anyone in the authority with the knowledge to identify the problem? The 2 pilots survived the incident (luckily) and are available for in depth questioning, not on just what hapened but also the rest of their knowledge.

[Denti]

@sheppey, completely wrong conclusion. There was a similar incident about 12 years ago at lufthansa out of HAJ at night. They struck a flock of geese on climb out and suffered a complete loss of thrust on one engine and heavy damage on the other one. Crew was a training captain and a fresh cadet out of their own training program. Both had started with the airlines flying school and went onto jets with minimum hours. They simply did what they were trained to do and landed after a normal circuit without the need to fly at 300ft AGL around the countryside for a considerable time.

The issue is not experience, the issue is training. Bad or no training and something like the case discussed in this thread might happen, good training and it is a lot more unlikely.

[MilPilot]

@Denti/Sheppey - This wasn't a complex emergency before the crew made it into one. So I agree with Denti that proper training would have lead to a lot better handling of this emergency.
I do however share Sheppey's concern when it comes to low hour pilots going straight to Airliners. They will be great as long as the answer is in the book and the training is good. I am not so confident that will be the case when the unexpected happens for the same reasons as Sheppey lists.

[before landing check list]

I met an Etihad 340 pilot the other night. I never met one of these before. By these I mean this guy may have been 25, he spent 2 years at their academy in Al Ain UAE where he got "about 200 hour with simulator" and he flew the C172 and the DA42. By simulator it was a procedural type only (switches, lights etc) Then he got a few hours in the A340 sim now he is in the right seat of a 340 with less then 300tt. I asked if they ever hand fly the thing. He said "company policy dictates autopilot on just after gear up and off on very short final (if at all). This is going to be the new normal. Draw your own conclusions from that.

[blind pew]

Henra
Great post surprising no one else picked it up.
If they did tip stall they would have had surprisingly high amount of bank!......

[BOAC]

sheppey - I'm not quite sure where you have been for the last 20 years or so! What sort of experience do you think is normal for a young F/O joining a jet fleet? Check the hours BA F/Os have on their first line sector. Everything you say is correct and desirable but not real.

Since this has now been dredged up, please note the Captain had 7540 hours, with 7200 on the 737 and 2410 in command on it. The F/O 2730 total and 2308 on the 737. Overall an experienced Captain, would you say? Well over twice the normal minimum for jet command, even in major airlines. Even the F/O was no 'spring chicken'.

The avation system with which I am familiar is designed so that experience is gained from a low level with time. I consider 'starting' hours to be desirable but irrelevant.

[DOVES]

clevlandHD:
Instead of wiki, you should read "Handling the Big Jets".

Valued sir.
I have read "Handling the Big Jets" when perhaps you were not even born, in 1966. And yet I keep a copy jealously.
Henra:
I hope this is not the source you take your aviation knowledge from.
Esteemed sir
I must confess that even after almost fifty years of profession, my thirst for knowledge forces me to drink from any source in order to improve my knowledge.
However I have at least 70 textbooks in my library about aviation:
10 volumes from the basic course, and about 3 volumes per plane I've flown: MB 326, Viscount, DC8-62, DC8-43, Caravelle, DC-10, DC-9 30, MD-80, MD-83, MD, 11, B737-200, B737-230, B737-300, B737-400: 14 x 3 = 52 + 10 = 62.

However, as @clevland has mentioned time has moved on and the designers have taken steps to mitigate this problem. Twist and taper/ relative chord thickness will take care of it.

Can I add autoslat, Elevator Power [down] etc. etc.. etc..
But why AF447 lost 38000 ft in 4 minutes? Perhaps because it went into stall, and the trim went all the way up, and there was fuel in the tail tanks?
But AIRBUS Does not stall !!!??? Or not???!!!
I repeat:
You all teach me that V2 = equal or more than 1,1 VMCA and 1,2 Vs. With such a bank (37,5°) Vs increment is 14%, so they were only: 1,2 – 0,14 = 1,06 Vs. “Deep” or not they were very very near to stall, and with the asymmetric thrust they had, God only knows why they didn’t get into a spin.

And their work load was increased by:
The Tower asking them, in vain, (and so repeatedly) to turn left instead of right
The stick shaker intervention
The GPWS activation

Were did priorities:
AVIATE, NAVIGATE, COMMUNICATE.
Go?
It seems to me that the airplane was leading them, not otherwise! And no crew coordination nor integration was going on.

[Big Pistons Forever]

What the Atlas Blue crew had was a routine bird strike after liftoff followed by the left engine rolling back with unknown damage. That's it. Nothing more. We all train for and practice this every six months. There is even a checklist in the QRH for this very event, plus a couple of memory items that are supposed to go with it. A TSB report and (so far) a 4-page discussion of this incident exists for one reason only: Hero Captain Syndrome.

I used to teach that the first memory item on any emergency checklist was "fly the airplane", followed closely by "take a deep breath" then "wait", then "Memory Items". "Don't panic", "don't be a hero" and "don't do anything stupid" were implied. Maybe not (sigh).

IMO the best post so far on this example of a complete and utter failure of professional standards of airmanship......

[blind pew]

I crashed landed is some trees yesterday and whilst I was driving to get a chain saw I discussed this incident with my very capable mate.
French Carrier pilot who banged out twice, flew off American carriers, won a top gun prize and flew and instructed on executive jets.

He said every pilot initially panics - I disagreed and cited a occasion when I made a mayday - but realised that he was right.

It's what you do after the bang or you realise that you might crash that is important....

Look at the BOAC 707 which crashed at LHR in the 60s where they decided to do an instant return and got the fire drill wrong.

The 777 splat at LHR where they carried out the after crash drill in the wrong sequence.fortunately there was no fire otherwise their mistake could have been disastrous.

AirFrance where the copilot was so scared he held on back stick pressure (allegedly).

In my old airline we had a captain lock himself into the loo when the destination closed in fog and there weren't a lot of alternate airfields.

Sadly none of us know what we will do when it hits the fan and most of us luckily will never have to face the mire.

What we can do is lots of professional training and that comes back down to money, professionalism and a realisation that we can all make mistakes......

Not forgetting aviation authorities doing a proper job and not looking after their mates...

[Capt Claret]

I reckon there should be a SILENCE button that shuts down the squarking banshee, when required.

A recent failure of a PFM Box, saw 15 minutes or so of constant squarking from Mrs Douglas (CAWS voice in B717). Gees it was hard to concentrate and troubleshoot! :eek:

[212man]

The 777 splat at LHR where they carried out the after crash drill in the wrong sequence.

In fairness to the crew - the company had taken the decision to split the QRH actions and placard them on the respective crew member's yokes, without realising the implications of the actions not being carried out sequentially.

[macdo]

I love the 'Capt. locking himself in the loo' quote above. In this particular case, it would have been they safest option for everyone involved!:ok:

[henra]

Henra:

Esteemed sir
I must confess that even after almost fifty years of profession, my thirst for knowledge forces me to drink from any source in order to improve my knowledge.
However I have at least 70 textbooks in my library about aviation:
10 volumes from the basic course, and about 3 volumes per plane I've flown: MB 326, Viscount, DC8-62, DC8-43, Caravelle, DC-10, DC-9 30, MD-80, MD-83, MD, 11, B737-200, B737-230, B737-300, B737-400: 14 x 3 = 52 + 10 = 62.



Doves,

I do apologise if I stepped a bit harshly on your toes.

However, does any of those 70 Books (specifically those about conventional tail airliners) mention the behaviour you cited (violent pitch up upon stall)?
If so, could you maybe provide a Link ?


But why AF447 lost 38000 ft in 4 minutes?

Because trim + elevator kept it in the stall against all natural tendencies of a conventional tail. That was what I meant when writing 'simulate a deep stall' by applying copious amounts of trim + elevator.

It is pretty safe to assume that had elevator + trim been neutral the thing would have dropped the nose upon stall. More precisely without continued trim + up elevator it wouldn't have got there in the first place it would have lowered the nose prior to that. It was only elctronics that overruled the basic flight mechanics and changed the behaviour to some extent.

[DOVES]

You do not deserve that I ignore your intervention. I owe you an answer.
Please consider that to "mitigate" the problem of wingtip does not mean to eliminate it.

Anyway take a look at the following movie:
737-400 testflight with wing stalls before autoslat. - YouTube

In any case the RAM Boeing 737-400 that on 6 June 2010 struck a flock of geese shortly after take off from Schiphol, if not in super stall, went dangerously close to a spin at a very low altitude and on a densely populated area.
I think something should be done because this does not recur, and because each of us reflect on how to avoid those mistakes in the future.

[Lookleft]

I don't think they were errors I think it was just incompetence. it doesn't matter how much you read if you don't have the skill or ability in the first place.

[Centaurus]

Anyway take a look at the following movie:

Not quite sure of the purpose in putting this movie on display. Was it to show the 737-400 has a benign stall with only a gentle wing drop and easily recoverable?

Was this a a Boeing manufacturer's movie or a company movie? And why was the flight director on display when it was not needed for navigational purposes. Typical example of automation addiction maybe?:ok:

[douglasheld]

I think the point might have been to demonstrate the tips generally stall first. Which I am pretty sure has nothing to do with this near disaster.

[wheelsright]

I think the issue here is why the pilot deviated from the rational to the irrational...

I think one possible reason, something that has been touched on previously, is that he wrongly assumed his aircrafts situation was worse than it actually was.

In the heat of the moment, of a multiple heavy bird strike, he wrongly assumed that he had had a "Sully" moment. Both engines losing thrust and unlikely to get back...

His reaction appears to be one of panick. His first thought was to get back to the airport and any procedures and rational decision making went out of the window at that point.

If he had lost both engines he would not have been able to make a turn and return to the airport. His only option probably would be to attempt a crash landing on open land or water immediately ahead.

If it had been the worst case senario he probably would have had limited options... But he still made the wrong decisions; under a moment of intense pressure he lost the plot and having set out on the wrong path continued on it.

I think that the most helpfull things to be stored in the back of his mind would have been a rehearsal of a worst case scenario on take off. This is the thought process of thinking that if you cannot save the aircraft maybe you can save people on the ground or with a lot of luck make a successful crash landing. If his mind had rehearsed the worst case then maybe, and it is just a maybe , he would have been able to make more rational choices and react to facts rather than imagined circumstances.

I think that the assumption that he was a bad pilot or did not know what the correct procedure was, in all likelyhood, not the case. It appears that he made the very human error of failing, under extreme stess, to behave rationally.

Luckily for all, the outcome was a good one. We all, at some point, will likely face a s#$t has hit the fan moment...we all hope that we will deal with that moment gracefully and rationally. To think that we are above failure is foolish. Of course, in the circumstances I doubt we will ever know the pilots perspective, but I doubt that he will happy with his performance.

Simulation only goes part of the way to prepare for high stress events...

[Lonewolf_50]

I think I understand the decision to put the gear back down right away (though I don't think it's the first thing I would have thought of in such a scenario) and certainly appreciate that the German team cited in a similar incident used standard procedures and SOP to get their bird safely back on deck.

What I cannot get my brain around is why, with an engine failure just after lift off, the good engine wasn't at full power (this is not a propeller driven aircraft) until landing profile for whatever runway they could get to was assured. Even with the gear down, full power might have helped them get a few more feet under them as the sorted out their situation.

Once the left engine had its poultry meal, wouldn't a desire to at least get to MSA be pretty high on your list of priorities?
If yes, then why not use all of the horsepower one has to do so?

All above considered, it's hard to argue against the criticisms on training.

If SOP and Flight Manual call for a "keep it clean, climb, level off, then trouble shoot, then configure, then land" there's a training issue to address that the company ought to take a hard look at.

Another of their crews may learn the wrong thing if the "these guys made it, but there was a simpler and safer way" lessons isn't strongly emphasized.

If other crews in the airline learn the wrong lesson from this (tip cap to "hero pilot" issue) then the chance that the next unexpected poultry meal on take off ends in tears increases. :=

[AdamFrisch]

I'm not defending the crew here, nor do I fly airliners or fly professionally, and have not read the whole report or all the replies. Just wanted to play devils advocate a little:}:

Two ways to lower your VMC (or whatever they call it in the airline world) at full gross weight if you don't need to climb is: get the gear out (adds keeling and stability) and/or reduce thrust on good engine.

1. Maybe it's possible that the captain had another partial bird strike/or somehow other performance issue where it was safer to not add full thrust on the working engine. Or maybe the thought he did and wanted to assess.

2. Maybe he was close to entering a dangerous VMC induced spin situation and reducing the thrust was his only way to get out of it when he ran out of altitude.

3. Maybe he reduced power during final manoeuvring to position himself correctly and allow himself to bank steeper without worrying about assymetrical lift etc, especially if procedures/terrain/traffic didn't allow him to do it into the good engine.

4. Maybe he opted to prepare for an emergency landing in the flattest country on earth and extended gear for that.

5. Maybe the extended gear to add stability?

It doesn't explain all of it, but could be a possibility. I've myself had a partial engine failure in a twin and know how confusing things can get. And the one thing that will instantly solve all your problems in assymetrical flight - except the obstacle clearance one (which wasn't a factor here) - is to reduce the power on the remaining engine. That's the fix-all.

[OD100]

That was my thought. But I'm thinking the captain and FO are not that smart to have even realized they were in position to land to the north at about the time they completed the turn.

No, this crew was simple stupid.

We train that ALL THE TIME.....

TOGO

PR, gear up

Fly profile

Run the checks

Delcare...


This is very puzzling.

I wonder if at ANY point in the interview with the flight crew if the question:

"...WTF were you thinking..." was asked.

If so, I'd LOVE to hear the response.

[Capn Bloggs]

I wonder if at ANY point in the interview with the flight crew if the question:

"...WTF were you thinking..." was asked.

If so, I'd LOVE to hear the response.
Arr, the world's greatest accident investigator.

When your child last had a prang on his bike because he was riding too fast, burnt himself on something, thumped his sister and made her cry, pranged the car in the wet after having his licence for a few months, did you ask the same question? And what was the answer?

If this does turn out to be a ballsup, the fact of the matter is that the system let these two pilots get to where they got. Short of a deliberate yahoo "I'm gunna try a low level run around town on one donk with the gear down because all that ops manual stuff is rubbish", these guys probably did what they thought was the best, using all their skills. Now if they didn't have any (or little), who's fault is that?

The irony is that these guys will probably be sledged far more, because they are alive, than the Suhkoi pilots.

They got the aeroplane back on the ground in one piece despite making life very difficult for themselves. Let's learn from it instead of asking "WTF were you thinking?".

We train that ALL THE TIME.....

TOGO

PR, gear up

Fly profile

Run the checks

Delcare...
You do, but did they?

[FullWings]

If this does turn out to be a ballsup, the fact of the matter is that the system let these two pilots get to where they got.
Possibly but you could say that about any human endeavour.
Short of a deliberate yahoo "I'm gunna try a low level run around town on one donk with the gear down because all that ops manual stuff is rubbish"
Unfortunately, that appears to be what they did. They had an Ops Manual which one would have hoped at least the captain had a passing familiarity with, especially concerning a engine failure on takeoff and the associated drills, on the basis of self-preservation let alone professional standards.
They got the aeroplane back on the ground in one piece despite making life very difficult for themselves.
But it should have been a non-event. If this had happened in the USA, they'd be looking at 'reckless endangerment'.
Let's learn from it instead of asking "WTF were you thinking?"
OK, what can we learn? Don't put the gear down following an EFATO and do a low-level cruise around a big city with the other engine on a random power setting...?

I'm in the camp that would really like to know "WTF were you thinking?" so I can avoid the trap that got them in this situation, assuming that it wasn't just blind panic, lack of knowledge, low standards, poor CRM, etc.

[Capn Bloggs]

"WTF were you doing?". I suppose that would be the first question you guys would ask the AF 447 crew as well. And the crew of just about every other prang. :hmm:

[FullWings]

"WTF were you doing?". I suppose that would be the first question you guys would ask the AF 447 crew as well. And the crew of just about every other prang.
We know what they were doing - the FDR, CVR and various bits of detective work tell us that. We'd really like to know what they were thinking and why, which is the reason the BEA have assembled a team of experts to try and come up with ideas in that direction...

[aterpster]

AdamFrish:

It doesn't explain all of it, but could be a possibility. I've myself had a partial engine failure in a twin and know how confusing things can get. And the one thing that will instantly solve all your problems in assymetrical flight - except the obstacle clearance one (which wasn't a factor here) - is to reduce the power on the remaining engine. That's the fix-all.

We're not talking about a Cessna 310, or such. A Boeing transport category jet with OEI simply does not have assymetrical flight issues at, or above, V2, and with the proper use of rudder. And, putting the gear back down defies the ground-rules of flying an OEI takeoff profile. Same with reducing thrust on the remaining engine. That is out of the question at this stage of a OEI takeoff profile.

[aggablinky]

Well, at least they made a safe landing, errors or not, its better that everybody disembarked on their own 2 feet, albeit a bit wobbly in the knees, no doubt! Does anyone know what the outcome was for the pilots?

[OD100]

I know what they were DOING. We all do. It's the thought-process that matters, and can help others...

So, until such time as the feds put implant a 'thinking recorder', my question remains the same...

WTF were you thinking?

Got it!?

[Pontius]

What I cannot get my brain around is why, with an engine failure just after lift off, the good engine wasn't at full power (this is not a propeller driven aircraft) until landing profile for whatever runway they could get to was assured.

Why go to full power on the good engine just because of an engine failure? If we imagine for one moment they did the correct thing i.e. raised the gear etc, then there's no requirement to go to full power. If they used an assumed temperature for take-off (and take it as read that they calculated that correctly) then this will allow for adequate performance in the event of an engine failure.

Of course, should you wish, full power is an option but let's not go down the incorrect road of saying engine failure automatically means full power on the good engine. If you're going to go on a low level navex around AMS with your gear down then I would agree that more power would be required than what these guys used but in a 'normal' engine failure scenario we know you can leave the power where it's set for take-off.

[PPRuNeUser0171]

I know what they were DOING. We all do. It's the thought-process that matters, and can help others...


Surely this is where the human factors and psychologists come into it all?

It seems to me (and I've not read the report but will do on the way in to work tomorrow) that the thought processes of the PF here were of a simple 'get it home nature' and the PNF simply stepped into line because he didn't have anything better to offer.

Both crew were in an unfamiliar situation - even if they had trained for it in the simulator real life is different - they knew that they had engine damage (probably didn't remember that they had TWO engines but just had 'engine damage' going through their heads) and they knew that to land they needed to have the gear down. Maybe with all the alerts going off as well the thought was to keep the gear down to remove part of the workload for later on?

I'm not saying what they did was right, it was careless and against common sense. It was pure luck they got down in one piece but I do think that what happened on the flight deck was simple 'get it home' syndrome.

Just one other thought - could they have not gone to a higher power setting on the good engine due to noise abatement? Could that aspect of flying have been drilled into them so much that it override other aspects?

[Lonewolf_50]

Thank you, pontius, appreciate your insight.

My "why not max power?" question had embedded in it an assumption (perhaps off the mark) that the rationale for leaving the gear down was "gonna land real soon anyway, leave it down ..." though my initial instinct would be "clean up" which apparently is close to what SOP is.

However, I seem to understand that the gents in the cockpit had begun to raise it, and reversed it in transit. Did I read that incorrectly?

[CISTRS]

Unfortunately, the geese had not filed a flight plan....

But seriously - I agree with previous postings - this should not have been a high profile incident. We are entitled to professional competence in these situations - not luck.

[bubbers44]

Well AF447 did everything wrong and everybody died. These guys did what they had to do in their opinion and everybody is ok. Sometimes sop doesn't work, remember AA DC10 crash at ORD, they followed AA sop and see what happened. These guys got it back on the ground quickly because they didn't worry about the checklist, they got it on the ground safely. Good for them. Depending on the circumstances, I might have done the same thing. I don't know the details.

TGU is one of the most dangerous airports in the world, #2, and the other airport in the mountains jets can't land at. If with all the hundreds of turkey buzzards in the valley I lost both engines of my 757 I had only one way to survive and that was stand it on a wing and land downwind otherwise you went into the hills with no chance of survival. No Hudson river there. Sometimes the pilots can handle the situation best by their talent and not just doing sop procedures. I like to follow SOP but sometimes I just can't.

[iceman50]

Bubbers44

Where were the hills and valleys in this case to argue the throwing away of SOP's? They were LUCKY, as well as the people on the ground that they overflew. If they had followed SOP it would have probably have been a less frightening event for all involved. As was mentioned in the BEA report about AF out of Guadeloupe, "surprise" probably had a major effect here as it was not in the script. Mind you if they had seen the birds during the take off roll then they might have been expecting something!
We all know you have flown into TGU, but his was not TGU.

[TonyDavis]

I find all of this talk about following or not following SOP's really worrying.

EFATO is not SOP's, its how the aircraft is certified, by not following it you are entering no mans land. Sure the aircaft can be flown with 90 degrees of bank or even inverted (Tex Johnson did it on a 707 and nearly got fired).

You are playing with peoples lives and should take that seriously, if you want to be a test pilot, do it without pax and over the sea (as long as I am not fishing there).

There are no if's and but's about EFATO, if you dont understand it ask someone to teach you.

[737-NG]

Wrong turn while climbing
Calling the gear back down as it is going up
Throttling the remaining engine up and down
Erractic flying, left, right, up down, steep turns
Not listening to ATC vectors (at least they didn't have to take out a Jepp chart)
Shuting down the dead engine after 4 minutes
Landing at 173kt with flaps 5 instead of the normal flap 15 engine out procedure (they actually left the flaps at take off setting just like the gear)

Obviously they got scared and wanted to get back down to the ground ASAP.

[FullWings]

These guys got it back on the ground quickly because they didn't worry about the checklist, they got it on the ground safely. Good for them.
No, they turned what should have been a non-event into a near disaster. It was "got onto the ground" in the most un-safe manner imaginable!

If they'd followed SOPs and flown a standard EO profile, we wouldn't be talking about it now.

Sometimes the pilots can handle the situation best by their talent and not just doing sop procedures. I like to follow SOP but sometimes I just can't.
Yes, there are times when you have to "think outside the box". A simple, contained engine failure is not one of them. Your performance is predicated upon a) having the gear up and b) at least the power you took off with on the other engine(s); anything else and it's lap-of-the-gods stuff.

It's a good idea to have a "plan B" (and C, D, E...) and to discuss or at least think about what you might do in certain scenarios before you commit to the sky. In the case we're looking at now it really seems like they were making it up as they went along and only through sheer good fortune got it back on the airfield in one piece.

At the point of failure, the aeroplane had the capability to climb to a safe altitude, fly an arrival, execute a missed approach and divert to a safe landing at an alternate airfield. This is what it is certified to do. What possessed the crew on this particular day to go way outside the envelope I'd really like to know... They had two opportunities to get straight back on the ground not long after takeoff but didn't take them, so it can't have been a desperate urge to return to the Earth's surface driving it. As I've said before, what were they thinking?

[40&80]

737ng.... Could you provide a similar sequential critique of the A.F. crews performance?...as this produced a different outcome.
I presently despair that neither crew were following SOPs or indeed most forms of basic airman-ship or any form of present day CRM which I read so much about.
If asking WTF were you thinking about?... regarding any incident I might have been involved in..this would by its hostile implication stun me into total silence and a 2,000yard stare as an Sop response.
Probably not the best opening accident investigation question in a "We are all in this together" age which I observe we are not.:ok:

[737-NG]

I wouldn't call it sequential criticism, just trying to analyse the facts; I think we all know that chair flying, or even sim training is one thing, but real life emergencies are something else. This could explain the added stress, and the fact that a pilot would have basic human reactions,(pulling up instead of down, not run through the checklist properly even though you know it by heart, etc) instead of a "well trained" pilot's reactions.

About AF447... Well we all agree that they messed up BIG TIME, but it was a dark black night, above the ocean, lots of alarms, unreliable instruments (at least what they thought) plus high altitude stalls are said to be harder to recover from usual stalls (I didn't try, and don't want to).

I actually think if one of the other pilots was PIC, they might not have crashed. Bonin kept pulling up, up, and up on that stick. On the CVR he even admits "we're descending but I've been pulling back for a while" and Captain Dubois tells him "no, no don't pull up". The PNF, from his words on the transcript, seemed to have grasped the situation a little better. But unfortunately, he did not take over command. And I can understand that.

What I really find incredible though, is NOT not being able to break the stall, (even though they had 4 minutes to do it), but GETTING INTO that stall in the first place. Bonin should have known better than recklessly pulling on the stick and climbing 3000 feet in a few seconds when they were already very close to max cruise altitude for their given weight, and the air temperature.

And, even more unbelievable, as you can read on the transcript, even though his colleague expresses his worries saying "we're passing 10000 feet", and then saying "damn it, we're going to hit, I can't believe it" Bonin replies "but what is happening here", proof he still had no clue what was going on, even though the altimeter must have been unwinding down at 10000ft/mn!!!!!

All the while Captain Dubois is sitting behind, watching them, saying a couple words and not doing much.

Once again, my personal analysis of the situation, we'll wait for the human factors specialists and what they have to say about that.

[barit1]

Over the decades, I have seen several episodes in which I found more respect for the airplane than for the PIC. Reading through this thread, I add it to my list.