Voyager Plummets (Merged)

[ShotOne]

By your own admission you’ve never seen the “shelf” you’re referring to and if you had you wouldn’t describe it as such. Although there IS a shelf immediately in front. It’s a few centimetres wide and, by good design, curved in profile making it hard to stow anything (which makes me wonder was, perhaps, his camera strap looped onto the sidestick to keep it there??)

Even then the unwise positioning was only one component of several negligent acts which caused this near-catastrophe. So if you are saying the hue and cry is undeserved I would take issue. Perhaps you would make a point of actually looking at the area before branding it a design fault?

[Chugalug2]

ShotOne, if you have a propriety interest in the design of the side stick mounting (there, is that an acceptable enough term for you?) then I'm sorry to have upset you by calling it a shelf. The point is that the loose object in question (with or without a strap) was somehow placed upon it in order that the subsequent events could occur.

If it can happen once it can happen again, even if this was the only time ever in your squillions of hours of operation that anything at all was placed on the side stick 'mounting' (with or without a strap). There, is that bland enough for you?

[beardy]

Chugalug2,
You raise an interesting point about highlighting the risk of a loose object interfering with the control column on Airbus aircraft when the armrest is down and the seat motoring forward. I do believe that it is a difficult, but not impossible set of circumstances, not impossible because it has happened. Once. And that is once too often.

I think perhaps you haven't seen the geometry of the seat, the armrest and the control column, It takes some doing to wedge anything in there, it is difficult to do accidentally, although obviously it can be. Little has been said about what occurs when the control column is forced out of the 'detent' it is in when the autopilot is engaged and what happens when the autopilot is disengaged by moving the control column. If you had seen the geometry and heard the warnings then perhaps you could understand why any extra mitigation of the risk would not be as successful as you think and may possibly not have prevented this particular accident. There are enough very obvious clues as to what had happened and to was going on which this particular pilot didn't interpret correctly. Cognitive dissonance can be exacerbated by unfamiliarity with the environment and a lack of confidence in the system producing the warnings.

[Chugalug2]

So what are you suggesting beardy, that if this particular pilot had taken more notice of the warnings being given then the accident would have merely become an incident and no-one (least of all his co-pilot) need have been injured? Well, no doubt, but he didn't, and they were. A great deal of mitigation is often needed where human factors are involved, or if you like try to make it 'pilot proof'. For goodness sake, no-one is suggesting a mega bucks solution (I did once but I think I got away with it :) ), just simply mark the top of the side stick mount (!) as a no-go area.

It may be next to impossible to re-enact the accident sequence, but evidently the SI managed to, and that evidence was presumably the clincher for the CM sentence. It happened, it can happen again, let's just try to make sure that it doesn't!

Or is Flight Safety just for wimps now, and we simply prosecute those who mess up, learning nothing from their mistakes?

[beardy]

Marking the area between the control column and the edge of the ledge is a cheap simple and elegant thing to do. It may help to prevent one of the holes in the cheese lining up. It would be nice to think so.
It would help you to visualise the situation if you went and had a look at an Airbus cockpit.

[Chugalug2]

beardy:-
It would help you to visualise the situation if you went and had a look at an Airbus cockpit.

According to Google this is the Flight Deck of a Voyager (ZZ338):-

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/1024x683/raf_airbus_a330_mrtt_voyager_zz338_501d9ee75cc682cbbd538d481 2fbe30870aebfc1.jpg

Yes?

[itsnotthatbloodyhard]

beardy:-


According to Google this is the Flight Deck of a Voyager (ZZ338):-


Yes?

Yes, but I don’t think you’ll gain much of an insight from a photo that doesn’t even show the armrest in question.
A look over an actual Airbus flight deck would be much better.

[Chugalug2]

Rhymenocerous, much thanks for posting your experience, a far more valuable input than my theoretical postulations. The point is it can happen, and if it can it will.

intbh, it is most unlikely that I will be visiting an Airbus Flight Deck any time soon. No amount of realising how unlikely an event it might be gets us very far, for the point is; it can, and has, and can again. As to the armrest v the side stick, here is a diagram (again courtesy of Google) :-

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1496x1156/a330_sidestick_arrangement_50992713297492760e2d810f9a35ec431 42e576c.jpg
I'm not sure what position the arm rest is at though. Lowest, middle, highest?

[itsnotthatbloodyhard]

I'm not sure what position the arm rest is at though. Lowest, middle, highest?

FWIW it looks unfeasibly high to me, such that the base of your hand would end up level with the wider portion at the top of the stick. Not how you’d want to try and fly it. The armrest would generally be much lower - the picture looks like a short person’s seat height with a tall person’s armrest setting.

[ShotOne]

Every aircraft with fore/aft adjustable pilot seats and a control column has a pinch point/design flaw/Achilles heel if, say, a flight bag or NVG case was placed immediately forward of the seat. By the same logic being used here, why do all aircraft not have warning hatching (or proximity sensors) there? More so since most types don’t have the flight envelope protection which saved the Voyager in this case.

[Chugalug2]

SO, I've never flown an aircraft with a motorised seat, and realise that they bring a new issue in themselves. A manually moved seat would immediately feedback any resistance to movement which would tend to be investigated when felt. However, it would be perverse to place an item in front of any seat between it and the control column, knowing that you would be moving the seat forward once sat in it. With the Airbus side-stick arrangement it is less instinctive, for the pinch point is not in front but to the side of the seat. Having looked at the Airbus 330/Voyager layout it would seem to me that there is indeed room to place a small object on the side shelf/mounting/ledge (select a/r). With the armrest lowered below the diagram height, as intbh says, it is then possible that such an object could be driven forward onto the sidestick as posted above, and as per the OP. Ergo, nothing should be placed on the shelf/mounting/ledge which thus needs to be marked as a visual reminder of that.

You are quite right to point out that the built in flight envelope protection saved the aircraft and its occupants.

[beardy]

FWIW it looks unfeasibly high to me, such that the base of your hand would end up level with the wider portion at the top of the stick. Not how you’d want to try and fly it. The armrest would generally be much lower - the picture looks like a short person’s seat height with a tall person’s armrest setting.
I disagree. The higher up the stick you hold it, the finer control inputs you make for the same hand displacement, think of the geometry of a lever (which it is.) You also get to rest your forearm on the armrest not leaving any muscles in tension. I was always surprised when young pilots held the stick at its base. They in turn were surprised at the finesse they were capable of when they changed their grip.

Chugalug2, your idea of a visual guide in front of the armrest is a cheap and simple one and has much to commend it. Whilst a picture paints a thousand words it is as nothing compared to handling what you are looking at. It would probably be worth going to see the real thing.

I managed to do a similar thing with a clipboard, when moving my seat in a a320 fixed based trainer a few years ago. Obviously not a situation physically similar enough to be meaningfully comparable to this accident, but the point is that I was unaware of the position of my clipboard when I adjusted my seat and suddenly the autopilot disengaged and the aircraft started pitching down. I thought there must have been a fault introduced by the instructor until I happened to notice the clipboard dig into the side of my hand while trying to correct the flightpath. It was before this incident and I thought nothing more of it until I heard the detail about it.

I am surprised that you used a clipboard instead of the clip on the table to hold any paperwork and also surprised that the clipboard wasn't on the table nor in the document stowage on the cockpit wall. Perhaps most surprising is that neither you, nor your instructor submitted an occurrence report of any type.

[beardy]

Every aircraft with fore/aft adjustable pilot seats and a control column has a pinch point/design flaw/Achilles heel if, say, a flight bag or NVG case was placed immediately forward of the seat. By the same logic being used here, why do all aircraft not have warning hatching (or proximity sensors) there? More so since most types don’t have the flight envelope protection which saved the Voyager in this case.
The seat doesn't even have to move. There is a very sobering film of an F4 that over pitches after take off resulting in the crew ejecting. When the pilot tried to pitch forward the control column was blocked by the navigator's....... camera.

[BEagle]

ShotOne a C-130 fatal accident occurred for the very reason you state. To assist in loading tall cargo, a pilot initially held the control column aft to improve clearance below the elevators. Then he decided to prop it in that position by jamming an NVG case in front of it - but forgot to remove it before take-off. As a result the aircraft stalled, killing 11 PoB plus 3 troops on the ground.

Surely trainee pilots are taught never to obstruct the controls with anything, nor place loose articles anywhere which could interfere with full and free movement of critical aircraft controls?

Some of the trash-hauling VC10 mob of the lesser squadron developed a habit of sticking their pens / pencils etc. in front of the radio selector box on the centre console. Presumably because when they used to fly in Blues, they had no pen pocket. Some still did when they changed to wearing flying clothing instead - if I found a pen / chinagraph / whatever on the centre console I would confiscate it! When one aircraft was prepared for a full air test, the engineering team told me that they'd found the remains of an RAF chinagraph amongst the TPI sensing microswitches underneath the control column. They also found a first class BOAC teaspoon under the cockpit floor of ZA141 which must have been there for ages as the aircraft had been sold to Gulf Air, flew for years with them, was then bought by the RAF, rebuilt by BAeS and flew as a VC10K2 for many years until the spoon was found!

Cabin crew were also taught never to pass food / drinks to pilots over the centre console, to avoid the risk of spillage - is it the same in the airlines?

I don't know whether civil A330s have the same OITs as fitted to Voyager, or simply sliding trays. If they don't have OITs, the sliding tray is quite a convenient place for loose papers etc. - but sound training, good flight deck discipline and proper SOPs should mitigate jammed control risk in nay aircraft without any need for visual reminders, cheap though some black and yellow hatching would be.

Flying an F-4 once, as I manoeuvred it a large part of the instrument panel surround came loose and fell out of position. I stopped what I was doing and advised that I would RTB. The pilot of the other aircraft queried this (typical of a flt cdr keen to gain hours for the boss's wall graph...), but I made the point that if the panel was loose, what else had been forgotten by whoever had been working on the jet.

[Megaton]

Don’t know what was in the A330 FCOM but other Airbus FBW aircraft had a note explicitly warning against putting objects on or around the sidestick. Also, haven’t read this thread in its entirety but the arm rest was raised or lowered to ensure that the the sidestick could be held comfortably with full and free movement and this was checked on the ground. It was often said that you held the sidestick like your best friend's todger ie rather gingerly and converting pilots were prone to over-controlling. If in doubt, let go often worked!

[Jhieminga]

Just curious, is the tray-type area immediately in front of the sidesticks on the photo above meant as a storage area? If so, I can see another gotcha, as in one seat position, using that tray will have you put down items beside you on that tray, but with the seat moved back, the same motion will have said items end up further back on the shelf, perhaps behind the sidestick. It is an unlikely event, but (if my interpretation of that tray is correct) could still end up as a hole in the cheese.

[Davef68]

Yes, but I don’t think you’ll gain much of an insight from a photo that doesn’t even show the armrest in question.
A look over an actual Airbus flight deck would be much better.

The armrest is visible at the extreme bottom left of the photo - so you get an idea of where it would end up when the seat is moved forward

[beardy]

Just curious, is the tray-type area immediately in front of the sidesticks on the photo above meant as a storage area? If so, I can see another gotcha, as in one seat position, using that tray will have you put down items beside you on that tray, but with the seat moved back, the same motion will have said items end up further back on the shelf, perhaps behind the sidestick. It is an unlikely event, but (if my interpretation of that tray is correct) could still end up as a hole in the cheese.
The seat never goes far enough forward for the tray to ever be beside you. It is always on the other side of the control column.

[beardy]

The armrest is visible at the extreme bottom left of the photo - so you get an idea of where it would end up when the seat is moved forward
Not unless you can take into account the distortion produced in the photograph, consider it similar to map projections.

[jimjim1]

Airbus helpfully have 360 degree images of their cockpits various in quite high resolution - here is an image from a screenshot.

https://static.airbus.com/fileadmin/backstage/Asset_management/A330-COCKPIT/cockpit330.html

https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/804x588/a330_sidestick_875d86c630d002dc1d85ea0aa55024b81db44585.png

[itsnotthatbloodyhard]

I disagree. The higher up the stick you hold it, the finer control inputs you make for the same hand displacement, think of the geometry of a lever (which it is.) You also get to rest your forearm on the armrest not leaving any muscles in tension. I was always surprised when young pilots held the stick at its base. They in turn were surprised at the finesse they were capable of when they changed their grip.

Sorry, but you’ve totally misinterpreted what I was trying to say. I think after many years and many thousands of hours, most of us have worked out that you can achieve finer control holding the thing higher rather than lower. And you can do that quite comfortably by holding it in the way Airbus clearly intended, and using little more than finger and thumb at the top of the stick to manipulate it. It’s just that the diagram seems to put your wrist a good way higher than would be comfortable or practical for most regular humans. At any rate, we’ve departed some way from the topic at hand, so I’ll leave it at that.

[jimjim1]

https://www.isasi.org/Documents/library/technical-papers/2015/orr-voyager_pitch_down.pdf

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/897x541/airbus_sidestick_with_camera_8cbcf43aa007aab22ee0d2d3ba0d798 3f34b83ba.png

[Chugalug2]

jimjim1, thanks for the 360 degree Airbus link, and especially for the pic recreating the jammed camera scenario. If ever there was a case of one picture versus a thousand words it is surely that one!

Interesting too that the final recommendation was:-
If possible, implement measures that could help prevent the placing of loose articles in close proximity to the side-stick.

Prevent is probably impossible. Actively discourage by training and appropriate marking aft of the side stick far more achievable I'd suggest.

[FlightDetent]

The armrest in the the picture is mis-aligned out of any reasonable position for its proper intended use.

(My comment above was intended to entertain, but only using pieces of reality snapped toghther in a funny way. It is absurd, but a consequence of logic shown above, I am beying just a messenger.)

The more is revealed, the less makes sense. Reality is sometimes stranger than fiction, but to suggest a technical modification - there is not enough underlying evidence.

[jimjim1]

I was not sure of the provenance of the image that I posted above in
https://www.pprune.org/military-aviation/533921-voyager-plummets-merged-52.html#post10338337
I have now read/skimmed the Service Inquiry and the image above is actually included in it - at apparently lower resolution in the public facing .pdf.

Here are further seat and sidestick images from the Service Inquiry

https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/1378x1202/a330_sidestick2_58349c5b686ac3c8f9d99d19cabfad4cc222531f.png
https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/714x302/airbus_sidestick3_53504e293cdca4e73e817f508b58b9526d235fc1.p ng


https://www.gov.uk/government/publications/service-inquiry-incident-involving-voyager-zz333-on-9-february-2014
Index to all documents

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414363/20150317_-_Voyager_ZZ333_SI_Report_Part_1.4_Part_1_Ex_Pub.pdf
First image

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414367/20150317_-_Voyager_ZZ333_SI_Report_Part_1.4_Part_2_Ex_Pub.pdf
Second Image

[Top Bunk Tester]

See Post #746

[Chugalug2]

See Post #746



Took some finding, a link to the page would have helped. For others wishing to view Post 746, it can be found here :-

https://www.pprune.org/military-aviation/533921-voyager-plummets-merged-38.html

How's your itch TBT? I don't know the answers to your questions, but suspect they can be generally covered by the OMG syndrome. He motors his seat forward to adopt the correct position that he should have been at all along, only for the nose to pitch sharply down and various alarms simultaneously set off. Perhaps some would have been more alert and quickly realised that the side stick itself felt wrong, while others are merely satisfied with casting the first stone. Whatever the answer to your itch, the accident was already being enacted. Better to have not perpetrated it in the first place, ie stay at the controls, and if you have to take some snaps, sorry pictures, wait for the co to return then hand control over to him. When you've finished taking them return the camera to your Flight Bag. Whatever you do don't place it on the Side Stick ledge, which will hopefully be clearly marked to dissuade you from placing anything there.

I'm pretty certain the defendant would ruefully agree with all that. Now just a case of convincing others...

[Top Bunk Tester]

Chug, apologies for lack of link. Maybe I need to get some steroid cream for my itch. Nothing further add really that hasn’t already been said, there are two sides to every incident/accident. But, like Brexit, it is unlikely you will ever convince the other side to capitulate. I am however pleased to see that the disproportionate sentence for the offence to which the defendant pleaded guilty has been overturned on appeal. The remaining counts that were returned not guilty have to be respected if nothing else.

[Chugalug2]

TBT:-
there are two sides to every incident/accident.

I think we are getting to the nub of things right there. There are two sides to every charge, prosecution and defence; and a great deal has been made pro and con that already. How can there be two sides of every incident/accident? They either happened or they didn't. If they did there can surely be only one 'side', to make every effort to avoid a repeat? There should be total agreement about that amongst 'the professionals who fly and support military aviation' (a condensed version of the PPRuNe Military Aviation Forum dedication)? That is the very foundation of Flight Safety, a notion that seems to have been forgotten amidst the general ballyhoo.

[Top Bunk Tester]

By two sides I mean one person’s recollection of an incident against the indesputable facts of the incident. We only have to look at ground witness statements to any accident you care to mention and you will find that statements vary vastly eg it was on fire; bits were falling off before it plunged, plumetted or fell; the engine sounded rough etc Whilst one would not expect highly experienced aircrew to express such wild views it can happen and they would all swear that their recollections were facts. Could this be what happened here? The handling pilot’s recollection of events was wildly at odds with the facts? This, of course, would mitigate the integrity question. However I still can’t reconcile this against physical interaction of armrest, camera, stick and arm/hand. Then the question of why were the images deliberately deleted from the camera’s memory card. However I’m just spitballing and have to recognise and respect the verdict of the court.

[Chugalug2]

An aircraft accident will always be the subject of an SI. This SI concluded that the defendant's camera had been driven into the side stick by the seat arm rest when it was motored forward. The fact that the camera had been placed in such a position to enable that to happen, and that the seat had not been already forward in the 'at the controls' position was the basis of the negligence charge to which he pleaded guilty. So much for the 'indisputable' facts.

He was also charged with perjury and making false record, to which he pleaded not guilty and was found not guilty. As you say, respect the verdict. So much for the 'itches'.

What bothers me about all this is the seeming lack of any 'there but for the Grace of God' reaction by other aircrew posting here. One pilot has had the moral courage to come forward and say that a similar occurrence happened to him, albeit in a ground simulator. Others have derided the notion that anything like it has ever happened to any other airbus crew, ie a loose object being driven towards the sidestick by the seat arm rest, ever. Even if that were true, this one accident should be enough to alert everyone to this Swiss cheese baited mouse trap. The SI calls for some form of mitigation and it has been postulated here; cheap, easy, and hopefully effective. Well, let's see.

A very frightening accident came close to being a tragically fatal one, saved indeed by the splendid self preservation logic of the Voyager itself. We don't get many such gift horses handed to us by aviation, and it behoves us all to learn as much as possible from it; whatever our role, whatever our job, be we civvie or Service. I suspect that one man at least has learned a lot, and it would be rather more rewarding for the rest of us to consider what we should learn and perhaps change our habits accordingly.

[airpolice]

I think we are in danger of missing a really good opportunity here.

Just as Princess Diana (as well as Dodi Fayed and Henri Paul) ought to feature on Seat Belt posters, this Pilot ought to be on a Career Continuation poster, pointing out that if you want the big money all of the time, then you need to behave, all of the time.

Captain Sullenberger: "I've got 40 years in the air, but in the end, I'm going to be judged on 208 seconds."

That's from the movie, rather than real life, but the principle is valid. You don't need to earn the money sometimes, you need to earn it all of time.