Thomas cook b757 incident, what a total mess

[g109]

Report: Thomas Cook B752 at Newcastle on Aug 17th 2013, flaps overspeed, fuel imbalance, landed below final fuel reserve (http://avherald.com/h?article=47b86849&opt=0)

[Capn Bloggs]

I read the report today. What a fantastic learning read; I would highly recommend it. :ok:

[atakacs]

Fairly poor airmanship I muss say. Everyone walked away but the outcome could easily be much worse.

I'm sorry but I don't buy the "demoted to first officer in March 2014 and that his salary would reduce significantly" bit as a contributing factor - I sympathize with his predicament but a professional can not allow such outside factor to impede on his performances. And if it did he was simply unfit for flight and should have reported as such.

[beardy]

It was not just the demotion and reduction in pay that was distracting him. It was the future direction of his career and life, as dictated by a fairly contentious decision by the company. Look at his age.

Agreed he should have done better on the day. But, perhaps because of the above, he should not necessarily have been flying on that day. Try taking yourself off the roster for psychological reasons; those same reasons will prevent you doing so. It is at this point that a good management team should be intervening, for crew welfare as well as safety. So why did the management systems fail? (Money?)

[The Ancient Geek]

Botched GAs seem to be a bit of a regular problem recently.
Is this a training issue ?.

This one also raises questions about fuel loads, why did they not have enough fuel for a simple diversion ?.

[Jwscud]

One thing that does always make me think about departing with min fuel to short runways is the "what if" regarding a Flap/Slat problem, and then going looking for a runway long enough to land on (might not be our Fuel alternate) and the fuel penalty diverting there with some form of flap hanging out. One to keep you awake at night!

I do sympathise regarding the Captain's situation though - he may have felt because he was making it through his flights he was OK, but some extra stress overloaded him. It's not like he's the first person ever to stuff the thrust levers forward and keep following the FDs down on a go around.

Also, out of interest, is TCX the airline the AAIB Ops guys do their flying with?

[qwertyuiop]

Sounds like he reverted to Airbus go around technique and then became overloaded very quickly.

[Fortissimo]

Jwscud,

The AAIB inspectors fly with a variety of operators, fixed wing and rotary, but they normally stay with one to keep the management simple (rostering, SOPs etc).

[The Ancient Geek]

A major issue with go arounds is that airline pilots rarely do them nowadays so they become scary. This leads to fouled up landings from unstable or below minimum approaches.

Back in the days of hacking around the game reserves every landing was fully briefed and on a hair trigger for a go around because they were an almost weekly occurrence due to wildlife etc.

Somewhere an essential skill has been lost, a go around is not a failure - it is a wise move and should be the instinctive reaction when in any doubt.

[expat400]

"After the preceding aircraft had landed that crew advised of a possible bird strike which prompted the tower controller to instruct MT-6107 to go around"

This has happened to me as well. What the f do ATC believe will happen if I land a 250 ton 747 on a dead bird? A complete waste of time and fuel.

[Airbanda]

This has happened to me as well. What the f do ATC believe will happen if I land a 250 ton 747 on a dead bird? A complete waste of time and fuel.

Not a lot probably.

OTOH if there's a possibility of a/c damage/debris or if bird was part of a flock that needs dispersing?

Full AAIB report is here:

Air Accidents Investigation: Download PDF document (http://www.aaib.gov.uk/cms_resources/Boeing%20757-236%20G-TCBC%2010-14.pdf)

[stilton]

'It's not like he's the first person ever to stuff the thrust levers forward and keep following the FDs down on a go around.'


Seriously ?


If you're that confused you have no business in the left or right hand seat, that's a basic flying skill that any professional pilot should have.


A go around in a B757 is simplicity itself, one click of the TOGA buttons and you get a nice, smooth 2000fpm climb and LNAV flies the MAP for you.



If you hit the wrong button(s) then just disconnect everything and fly it.


To get to 287 Kias with the flaps out is just unbelievable.

[TCAS FAN]

expat400

Very pleased to hear your viewpoint, takes me back to a very heated post comp check with a local examiner when I had the same scenario, landing aircraft reported possible birdstrike on the runway, I warned the succeeding traffic (DH8) and cleared him to land. "Should have sent him around" was the examiner's response. "Why?" to which no coherent response was received, just "I'm not happy with your actions" to which I replied "well pull my f****ing rating". Funny that never happened, nor was the occurrence written up on the de-brief, possibly for fear of my right to formally respond on the same form.

[HEATHROW DIRECTOR]

<<What the f do ATC believe will happen if I land a 250 ton 747 on a dead bird? A complete waste of time and fuel.>>

A somewhat uncharitable comment if I may say so. I was on duty at Heathrow early one morning when many bird strikes occurred. Both runways were closed and a number of aircraft were sent around. During subsequent runway inspection over 200 carcasses were removed - a record at the time. ATC will take action to preserve safely; that this may not be agreeable to some pilots is unfortunate.

[fireflybob]

Have not read the whole report in detail but was this really a (subtle) case of some form of pilot incapacitation?

Much money and resources seem to be pumped into the hardware but scant attention seems to be paid to the (human) software.

In safety critical industries the humans need to be functioning correctly in every respect.

[Discorde]

I remember that when I was a Type/ Instrument Rating Examiner on the B757/767 (I'm retired now) the 2-engine go-around was frequently performed untidily in the sim, so much so that I included this procedure in my 'How To Do Well In The Sim' (http://steemrok.com/howtodowellv3) paper. It's disappointing to learn that crews are still getting themselves into trouble flying this manoeuvre.

Have not read the whole report in detail but was this really a (subtle) case of some form of pilot incapacitation?

That's why there are two pilots in the cockpit, both of whom should be adequately qualified, experienced and not fatigued.

[expat400]

HEATHROW DIRECTOR

I get your point but you're talking of an extreme event that might happen once every hundred years...
It will of course always be a judgement call when to close the runway. Someone reporting "a possible birdstrike" is not enough according to me. A warning to the crew on final and slowing down the following approaches to create a gap for an inspection should be enough. If the commander decides to go around he can do it but it should not be a mandatory action.

[slowjet]

Incident occurred over a year ago and at that time,the Captain was facing job re-assignment in March of this year. I don't see a report date (although one is implied). Anyone know how the unfortunate Commander was treated by TC ? A major incident would normally lead to suspension(on full pay) pending the result of a full investigation. Just curious as to how different companies treat these cases. One company I worked for, a Capt scored a major black. Back at Base, Chief Pilot interviewed the offender and said, " Your employment is terminated with immediate effect. You now have 30 minutes in which to talk yourself back into employment ". I quite like that. Oh & before I am shot down, I do agree that the TC incident was more than a 'major black' but still curious about various company's handling of incidents.

[kcockayne]

Nowadays, with everyone waiting to jump on your back, maybe some ATCOS feel it is more judicious (& self preserving) to initiate a go around. I would not necessarily have done the same, but I grew up in the era of "operational common sense" & not in that of "blind pedantry". Not that I am in any way accusing this ATCO of being pedantic ! (just a commentary in one aspect of modern day aviation).
Nevertheless, I would not criticise the ATCO in this case without knowing exactly what all of the factors were; &, even then, I would support him in trying to deliver a safe service & protect his licence .
There is often more than meets the eye to situatons.

[Una Due Tfc]

If the Atco had not advised the go-around, and the 757 had gone on to ingest debris on the runway, that Atco would have been f****d

[Heathrow Harry]

bit of a Horlicks TBH - they got behind the 'plane, panic set in, and never really caught up

given that they had plenty of fuel for NCL and nothing was visibly going badly wrong they should have asked for a stack somewhere and spent a few minutes calming down, checking what was connected and what wasn't and reconfiguring the aircraft

[Centaurus]

I sympathise with the crew and blame the operator. They were almost certainly trained from the very first simulator type rating session to use the automatics right from the start - instead of first being taught how to fly the aeroplane with their hands and feet. A classic example of todays training which accents the full use of automatics regardless if it is appropriate for the circumstances. Do you really need an automatic pilot to do a visual go-around? Of course not. I was amazed that the company even tells its crews to use mnemonics to remind them what they must consider. I thought mnemonics were only used by student pilots in the initial training. But for airline pilots? WTF

[Capot]

Small comment from the observer gallery; I would rather be a passenger in an aircraft that has a severe bird strike in the last few feet of an approach, or after touchdown, than be a passenger in an aircraft that has a severe bird strike in the first stages of a go-around.

So if ATC or a crew reports a runway bird strike on the landing aircraft in front of the one I'm in, next week, I hope the PF continues the landing while being alert to the possibility of a bird strike and loss of power.

[RunSick]

Back to the ATCO possible ways of dealing with this situation, a few weeks ago we had a birdstrike (to the fuselage) crossing the threshold for landing. I reported it ASAP and tower asked the next plane if they had copied the info and if they where happy to continue, which they did. AFTER this plane landed all others were vectored for the other RWY as the one we (and the plane following) had used was closed.

I feel giving the option to the crew is better than suddenly instructing a go around (if not REALLY required). The crew might still elect to go around but would have some time to prepare. A few seconds is more than enough to highly improve the chances of the Go Around being flown as they are supposed to be flown. IMHO.

[Mac the Knife]

Have to agree with Capot.

Nevertheless, after many years of PPRuNe-ing it seems that a major review of the automatics/pilot interface is long overdue, as well as recurrent training in manual flight and abnormal situations.

I've seen this sort of Horlicks in modern operating theatres and the results can be scary - thereas out in the bush, in primitive theatres, everyone is tuned to manual and knows what to do.

[fireflybob]

I remember that when I was a Type/ Instrument Rating Examiner on the B757/767 (I'm retired now) the 2-engine go-around was frequently performed untidily in the sim, so much so that I included this procedure in my 'How To Do Well In The Sim' paper. It's disappointing to learn that crews are still getting themselves into trouble flying this manoeuvre.


I was also a T/IRE on the B737 and that was also my observation.

I think a lot of this is sheer lack of practice. How often do pilots do an all engines Go Around (either on line or in the Sim)?

In this situation given the all engines performance, the low relative level off altitudes are a potential threat and IMHO should be briefed for.

That's why there are two pilots in the cockpit, both of whom should be adequately qualified, experienced and not fatigued.

Discorde, of course! But taking over in this situation requires a lot of advocacy.

[cossack]

Here we have direction from the airport company that for a "possible" bird strike we will advise landing aircraft and continue operations until the runway can be inspected unless a pilot reports seeing something on the runway.

For a "confirmed" bird strike the surface is closed and must be inspected. No discretion.

Controllers and pilots should be allowed to use their discretion regarding bird strikes and other wildlife. Last night we received a phone call from the fire service watch room reporting a deer very close to the landing runway. A deer is much bigger than a bird so we suspended operations on that runway immediately. Only one aircraft missed the approach, all others were re-positioned to the parallel departure runway.

[Two's in]

I was amazed that the company even tells its crews to use mnemonics to remind them what they must consider. I thought mnemonics were only used by student pilots in the initial training. But for airline pilots? WTF

Mnemonic - any learning technique that aids information retention.

The mnemonic in this case is intended to assist in regaining full situational awareness by highlighting the principle considerations. The time when you will forget or omit a critical factor is exactly when the workload has rapidly increased and the hairs on the back of your neck are standing up. To associate mnemonics with something done only by students during training is a fascinating concept in itself.

[Discorde]

But taking over in this situation requires a lot of advocacy.

Not so much 'taking over' - more a case of helpful call-outs. 'Pete, we need a pitch of 15 degrees for go-around', or 'Pete, speed's a bit high for the flaps we've got.' You don't actually need an aircraft or a sim to practise go-arounds - you can run through the procedure sitting in an armchair at home or while driving to work.

The duty started at 0500 for this crew. NCL to FUE and return is a long day, especially after a start this early. It's unlikely their mental faculties were functioning at max efficiency during the approach to NCL.

There is a significant problem with fatigue - how can a pilot blame fatigue if he is involved in an incident? The legal bods will say - you've broken the law by flying when fatigued. So what will pilots say? 'I was not suffering from fatigue as far as I was aware.' What else could a pilot say without being accused of breaking the rules?

Another consequence of fatigue is that it impairs judgement. This means that a person suffering from fatigue might not even realise it. They may not realise that they are not in a fit state to do aircrew duties.

[5 APUs captain]

At least they have "level 6" english I beleive... what is everything in aviation now. And the briefing has been done for both runways and all kinds of approaches. Just TOGA has been forgotten to be depressed. Well done!
757 is easiest for GoAround- after pressing TOGA it slowly climbs with 2000 ft/min only - piece of cake!

[36050100]

I think a lot of this is sheer lack of practice. How often do pilots do an all engines Go Around (either on line or in the Sim)?


In my company, it's twice per year. The Cat 2/3 revalidation is always done within FCL/OPS checks and at least one of these approaches results in a go-around. Admittedly, the opportunity might be taken to make an engine failure the cause of the go-around, but since a single-engine go-around is always flown for the OPS/FCL part of the revalidation, it's usually thought more "interesting" to find another reason to cause a go-around from the Cat 2/3 approach.

[RAT 5]

The mnemonic in this case is intended to assist in regaining full situational awareness by highlighting the principle considerations. The time when you will forget or omit a critical factor is exactly when the workload has rapidly increased and the hairs on the back of your neck are standing up.

And due to this 'hairy neck syndrome' you forget the mnemonic. Then what? If you need these things as a crutch the perhaps you don't understand the basics and need more awareness.

Regarding the horlicks of simple 2 engine manual G/A's. I was B757/767/737 TRI/TRE in various companies. It was common complaint/observation that this manoeuvre was performed unsatisfactorily. How dis they know? Because it was when it happened on the line. When was it trained/checked? Never, after the first initial TQ course. The prof check is a slow single engine G/A and the LVO is an auto G/A. Push the button and let George do his thing. Solution; more recurrency training of a known weakness. Resulting answer; nothing extra at all. Sad day for training departments. No crashes on G?a so no further training required. Incidents? Many, but all survived. Sad days indeed.

[4Screwaircrew]

I have flown both 737 and 757 as a line pilot, and held TRE on both; on line I've flown go arounds in both types with and without the autopilot. On line I've never had a bad experience but it has been my habit for many years to brief not only the pattern but the physical actions of the go around, and encourage the F.O. to do the same.

By hand or by autopilot it is not a difficult thing on either aircraft, but if you haven't thought it through the startle factor has the potential to make it difficult to manage correctly. I have watched 2 TREs botch an all engines go around in the sim when they went around having expected to land off an approach, they wouldn't have damaged anything but it wasn't pretty.

Anyone can get it wrong, dealing with the stress after that can be very difficult.

[olster]

Startle factor now recognised as pertinent ; 'are you ready ? ' plus take a deep breath for a 'high altitude ' go around now recommended . Not really keen on over criticising post event flight crews but this is not impressive nevertheless . Significant difference between Airbus and Boeing types but Aviate , Navigate, Communicate (ANC) is the Airbus (now) mantra which applies to Boeing as well albeit different . Company issues ref job etc should not be a factor for professional and appropriate conduct unfortunately missing in this case . Report is a horror story and regardless of seniority number the LHS competency is not at the level required. All engine go arounds continue to cause industry wide problems so will probably appear as an exercise within ATQP sessions more frequently . Sobering and thought provoking post - mortem in and out of TC undoubtedly .

[lookoutbelow]

The big learning point I think that should be taken from this is that when a GA is required from well above minima and in good WX, it may well catch you by surprise, but there is no desperate rush, just a couple of seconds of thought can avoid a lot of heartache thereafter. Regular briefing and mental rehearsal can help greatly (as with the RTO). I do likewise for GPWS and Terrain escape Manoeuvres during which there will likely not be time to ponder! If WX is close to minima, briefing carefully the GA and required actions inc monitoring from the PM required - also a v short 'hot' brief covering the pertinent actions at say between 1000-500R I find is useful.

On approach, ensure thumb is guarding behind the GA switch, not beside the AT Disc button - guards against the motor slip of disconnecting the AT instead of pressing GA. If the AT is to be disconnected, move thumb from GA switch to AT disc switch - press twice - then back to guard the GA switch. Both pilots check GA/GA/GA/CMD
Every approach should be flown as a potential GA.

Know how to fly the aircraft manually and remember the approx datums (that the FD's/AT use during day to day Ops):

T/O & GA - initial 15deg nose up - TO/GA thrust 1.60 EPR (will do)
Accel - 10 deg nose up - 1.50 EPR (will do)
Clean level - 4-5 deg nose up - 1.18 EPR (will do)

If FD are not giving you what you expect, AP disc (as it was in this case), both FD's off, back on (V/S, HDG HOLD) then start again.

On my current operators 2 day recurrent check we are doing 2 or 3 two engine G/A's per crew. A good idea as a botched 757 GA has very nearly caused a hull loss before - see Icelandair incident (very informative read) - I would say approx 1/3 to 1/2 of the line crew are making 'sloppy' or occasionally worse errors with the manoeuvre. Worth covering..

Current B757/B767 TRE/TRI/Base Trainer

[RAT 5]

Aviate , Navigate, Communicate (ANC) is the Airbus (now) mantra which applies to Boeing as well albeit different .

Really? I'm a Boeing man and never known anything different. It was drummed into me in B732 days and I've been drumming it into every student I had on B757/767/737 over the last 25 years. Plus: Attitude, attitude, attitude and power as necessary = performance.

An RTO is never a surprise; take off is a bonus: a Go Round is never a surprise; landing is a happy conclusion to the approach. Somewhere on approach run through the G/A actions in your mind. An ATC wave off is always a possibility; an unstable approach at 500' is always a possibility; a quick shift in wind at low level causing a float is always a possibility: the G/A is never a surprise and should be a doddle to the alert airman. It's what the pax expect. Professional standards at all times.

[foxmoth]

A lot of talk about GA, most can do this OK from normal GA height, it is when you do this from height it catches people out - try it in the sim with a level off at 2,000' and given the GA at 1600' or even worse 2,100', it will catch many out who think they know how to do it!

[RAT 5]

As was said in 'comments on the AV report article' the G/A was advised at a decent height. There was no rush. We are conditioned to making G/A's at minima with minimum height loss. Here was a case where there was no need to panic/rush. There was no need to minimise height loss; it could all be done in a leisurely manner. That involves a clear understanding of the manoeuvre and a good situational awareness. A G/A should not be a 'trained monkey' manoeuvre; there are variations on a theme and an alert pilot should feel able to adjust the basic manoeuvre to suit the scenario. The approach could have been continued to a lower height and then when ready, and communicated to the PM, a relaxed G/A initiated. Crews should feel relaxed about exercising judgement in such situations.
I feel simulator scenarios do not reflect enough 'real world' scenarios and thus there are 'real world training' opportunities missing. This is not the first such mess up, and perhaps not the last. I've seen even worse in the sim. "Go Round" called, power added and the a/c descended down the glide path because TOGA had not been pushed. The FD was still in Glide Slope. Ouch. Where was the motor action of raise the nose to a basic attitude to convert descent into a climb? Look through the FD.
Will the lessons be learned? Hopefully.

[fireflybob]

A lot of talk about GA, most can do this OK from normal GA height, it is when you do this from height it catches people out - try it in the sim with a level off at 2,000' and given the GA at 1600' or even worse 2,100', it will catch many out who think they know how to do it!

foxmouth, agree - so it needs to be specifically taught and practised on a regular basis then, as I'm sure you know.

[Mikehotel152]

Indeed, 'there was no rush'.

During my first go-around, years ago as a very green FO, my training Captain calmly told me our speed was a little high and was I ready for a go-around. I said yes and we performed the manoeuvre calmly. More recently, now as a Captain myself, upon receiving an unexpected out of limits wind report I asked my FO an identical question and the outcome was the same. Taking a breath makes all the difference, but I accept that it's not always possible to do so.

Most jet aircraft can be a handle once the TOGA is pressed and we do not practice 2 engine go-arounds enough in the sim due to time constraints, but essentially it is not a complicated manoeuvre especially if the non-flying pilot is proactive. Similar to a normal departure?

But if you both get behind the aeroplane it is very tricky to recover. And this crew never got the chance to take a deep breath and re-mount their runaway steed. IT never rains, it pours!

[olster]

Rat 5 I completely concur ; however it would appear that the ANC is being overlooked with task saturation - this case would be a good example - Airbus are hammering 'the basics ' which would presumably have been second nature back in ( mine as well ) the day . The horrific AF447 drives Airbus in terms of 'encouraging pilot skills ' but undoubtedly the skill level is globally reducing. Very interesting read in this month's 'Vanity Fair' with ref AF447 and the conclusion is that modern aircraft with highly developed automation are incredibly reliable but when going wrong there is the possibility that the modern pilot does not have the skill set to deal with it. I don't have the answers and don't wish to condemn the modern pilot ; as an industry we have allowed this to happen ( skill level degradation ) in tandem with the automation .We weren't all Chuck Yeagers back in the day but most had the basics of instrument flying. The blame lies in many areas not least the cost imperative so beloved of the LCCs ; although I have to accept that the safety record of the major players ( blue /orange ) are pretty impressive.

cheers

[Ranger1]

This was a very unfortunate incident. The individual concerned made a mistake and we can all learn from it. However, spare a thought for his feelings, imagine how you would feel given some of the comments on this thread. He undoubtedly feels bad enough already! Hopefully he has not read some of the uncharitable remarks posted here.

Many years ago an old boss of mine put the following statement in a news letter following a lot of derogatory comments made about another fellow professional who made a mistake "for those of you who think this could not happen to you, it probably will". Incidents and accidents happen to even the best pilots. Learn from their mistakes but don't judge too harshly as one day it could be you!

Many an unblemished career has been left in tatters by one lapse of judgement or mistake, sometimes with terrible consequences. It would be a mistake to think it only happens to bad pilots.That kind of thinking will make you a statistic!

I hope this pilot finds some comfort and support from his more enlightened colleagues. I have found the more enlightened posts on this thread very interesting and informative. Shame about the rest!

[dash6]

Do our (retired?) trainers on this thread now regret all the SIM time spent droning around on LOFT exercises.How many pilots have been offered the option of practicing a manoeuvre;"anything you like,but of course it will be assessed" Er,no thanks.....?

[LIMA OR ALPHA JUNK]

There for the grace of God go all of us. Have fire-walled the throttles myself on the 757 in the sim, forgetting to click the switches, having been on the Airbus previously. I am sure I am not alone.

[fireflybob]

Do our (retired?) trainers on this thread now regret all the SIM time spent droning around on LOFT exercises.How many pilots have been offered the option of practicing a manoeuvre;"anything you like,but of course it will be assessed" Er,no thanks.....?

dash6, don't blame it all on the trainers who are part of the orchestra but not the conductor! Training courses and syllabi are usually drawn up by the higher echelons of management.

You seem to have a somewhat jaundiced view. Certainly all the trainees I dealt with were often given the opportunity to practise manoeuvres of their own selection when time permitted after the mandatory items had been completed. And certainly in my case such manoeuvres were not assessed.

Believe it or not but quite a few of us trainers did the job because we genuinely wanted to see our fellow colleagues reach the highest standards possible in a friendly and helpful environment.

[Judd]

Look through the FD.
"Looking through" the FD is an unnecessary distraction. It should be turned off rather than looking through it to see what is on the other side. Flight Director addiction/dependency has been the cause of many cock-ups. Others have no problem in switching off the FD and can seamlessly fly raw data just as well

[caber]

Good Lord, as an American on a mainly European site is it really true that when you ask if the crew wish to perform additional maneuvers after the boxes have been checked that those maneuvers are graded? As a former and most likely future LCA I find that appalling.

Once a crew has checked their boxes, extra time is for them or myself to look at things we think might be important, not to find an extra way to destroy a career.

Shameful if true. Extra time is just that, extra. A crew that wishes to practice something "just to see" gets to do so, no strings attached.

[Lord Spandex Masher]

Never has been in my experience. Besides how do you grade " fly upside down under London Bridge"?

[JW411]

the report also raises a fundamental CRM point. On Page 3 it says "... the co-pilot started to action the QRH ........ He also continued to operate the radio". I think that is a bad move and is a recipe for incomplete checklist procedures and possible disaster. To try to action the QRH and deal with ATC at the same time is likely to be a very bad move and so it proved. He was rapidly being overwhelmed.

In my last company, it was SOP that when something went wrong, the call was:

"My aeroplane, My radio and Your checklist".

[Capn Bloggs]

"My aeroplane, My radio and Your checklist".
So you have two separate operations going on in the cockpit: one flying, getting (probably quite critical) ATC instructions, as well as making instant snaps about where to head, levels and the other head down going thru the QRH (with no interruptions).

That is not necessarily better CRM, not to mention throw in "that switch is in your area of responsibility, turn it off will you?".

[Lord Spandex Masher]

Yep, and then, when we've got a second or two, bring the other guy up to speed. It's not rocket science.

[helen-damnation]

Having flown Airbus and Boeing, one of the things I like on the 'bus, not SOP but very useful when things start to unravel, is the ALT button.

Recognise the approach isn't going to work, press ALT. The a/c levels, brief conversation along the lines of "we're doing a GA, are you ready?" and then off you go.

Obviously only done when the situation permits (not minima) but could save the pension fund! (Also useful on the 4 holer, 2 eng GA).

Unfortunately it won't work on the Boeing below 1,500' and possibly not above?

[Flaperon75]

very useful when things start to unravel, is the ALT button......press ALT. The a/c levels

Huh?

Do you mean the Vertical Speed knob?? Pushing the v/s knob sets v/s to 0 and levels the aircraft....

Pushing the Alt knob will put the aircraft into a managed climb/descent.

[CargoOne]

Imagine for a sec it was Asian or East European or South American airline and crew - the sh*t storm would be blasting 25 pages long by now. But as long it was our fella TCX that's a mistake can happen to anyone.. Right?

[Agaricus bisporus]

Whichever way you slice it this is a poorly skilled Capt having a bad day out with an equally inadequate FO.

There is no way that a 13,000hr Capt with 1400 on type should be thinking "I should be doing something with my thumb..." during a go-around.

There may be many reasons for it but even fluffing an unfamiliar manoeuvre like a 2 engine g/a is no excuse for the litany of operational blunders that followed, nor for the FO to allow them to occur. This all smacks to me of both pilots operating in normal conditions at the limits of their ability and finding that one little upset overturns the whole shebang. I know, I've been there.

My company recognised some time ago - from flight safety reports - that the 2 engine g/a, esp from midway down the 'slope was the most cocked-up manoeuvre simply because it is (was) not practiced regularly, if at all, in the sim. A campaign was instigated to remedy that and afaik the problem was solved.

This incident seems to be a timely reminder to any of us with weak spots in our skills to take a good hard look at ourselves and ensure we get them patched up, and especially for FOs to ensure they have the confidence and skills to back up and support, and in extremis manage a floundering Captain.

It is also a wake-up call to training depts to look at all operational scenarios and ensure that sim training covers these thoroughly in addition to the box ticking.

I feel for the crew, even more for the pax exposed to them but feel sure that with sensitive management these two guys should return to the line much better equipped to do there jobs with confidence. I hope so.

[helen-damnation]

Do you mean the Vertical Speed knob?? Pushing the v/s knob sets v/s to 0 and levels the aircraft....

Flaperon75

Good question but no. I mean/meant the ALT pb (as in ALT HOLD) and not the ALT knob.

I haven't tried the V/S.

[Fred Flange]

Anyone who suggests the previous forced relocation and forthcoming demotion isn't relevant is as moronic as the management who facilitated it in the first place.

Incidentally both pilots had been forcibly relocated (they could have took redundancy I suppose) which effectively multiplies the effect by 2 and possibly increases the effect to the power of 2. The problem is quite widespread and is to going to get any better soon as the displaced/demoted have no priority to return to base ahead of any other 'senior' pilot who fancies a change of scenery.

The problem with stressors like that is nobody really knows how it affects themselves and will no doubt feel as though they are coping. Suggesting that they should be able to self diagnose the problem and then call in to say they are unfit is quite ridiculous isn't it?

I personally feel that this is the biggest single factor. If other factors such as training or type changes or ability were the main factor then there would be a lot more cocked up go arounds in this company.

To answer the more recent posts, GA alt hold does the job you are trying to describe by the way.

[Flaperon75]

Good question but no. I mean/meant the ALT pb (as in ALT HOLD) and not the ALT knob.
....I'm getting confused now. I thought you were talking about the Airbus?? There is no ALT pb on the bus.

[Greek God]

I don't know if its changed(Boeing wise) but a big difference between Boeing and AB was/is the pedanticism of calling out the FMAs. It was drummed into everyone on the AB course that EVERY FMA change is called and acknowledged on the AB but
I don't remember that to be case with Boeing (75 or 73) no doubt most operators use the manufacturers SOPs as the framework for their own but this practice, or rather lack of, is one I cannot understand. Similarly on the Boeing the FMC operation was the duty of the PM below 10k while the AB allows PF to start pressing buttons from gear up!
Surely its in everyones interest to get general automation training, principles and awareness standardised across different types(and operators) to try and remove at least a small slice of expensive emmental?
But then that would mean cooperation between B & AB!! Silly me.

[eckhard]

Good question but no. I mean/meant the ALT pb (as in ALT HOLD) and not the ALT knob.
....I'm getting confused now. I thought you were talking about the Airbus?? There is no ALT pb on the bus.


The ALT button on the FCU seems to be an alternative option on the Airbus. On my fleet, we don't have the ALT button; instead, we have an EXP button. Pushing this button EXPedites the climb or descent, by adjusting the target speed to (I think) green dot (climb) or Vmax (descent).

Before anyone jumps in, I don't have access to the manuals, so the details may differ, but the principle applies..........

Anyway, while reading the report, I thought that it resembled one of my better sim checks!!

[JW411]

Capt Bloggs:

Having just re-read the AAIB report for the third time, I note on Page 62 it states:

"A section of the OM concerning emergencies after V1 stated that the PF should be responsible for radio communication when the PM was carrying out QRH drills. This division of tasks was not explicitly associated with any other procedure."

Perhaps it should?

dash 6:

In your posting #43 you are basically asking how us TRI/TREs are feeling now?

Let me give you a history lesson. In the old days, it was called the Base Check and Instrument Rating. The CAA required that you hand-flew all of the exercises (V1 Cut, NDB Hold, Engine-out ILS to minima, G/A, NPA which was usually an NDB followed by a Circling Approach to Land).

The only time that the autopilot was available was while you conducted a briefing and for obvious exercises like Cat II or Cat III.

The whole plot was changed with the introduction of JARs whereupon the automatics were available for every exercise except for one hand flown ILS and G/A with an engine out.

As a TRI/TRE I found this quite restricting in my ability to examine.

I always thought that the old CAA Base Check/IR was a bit like the Seven Labours of Hercules but the new regime, in my opinion, was far too lax and seemed to me to be a recipe for concealing weaknesses that could have been put right with proper instruction and further training.

Quite frankly, I find this incident extremely worrying and I find it extremely hard to believe. The whole bloody scenario was self-inflicted and got close to a disaster.

Somewhere, somehow the regulatory authorities have to get a grip on the situation. I still find it impossible to understand how AF447 happened nor do I even begin to understand how you can stuff a perfectly serviceable B777 into the seawall at SFO in CAVOK conditions.

You must understand that the TRI/TREs are hog-bound by the CAA/JAR/EASA into what they are allowed to do in teaching/examining.

How many of you out there could honestly tell me that you could pass an old-fashioned CAA Base Check/IR?

By the way, I actually think that LOFT when properly used is invaluable.

[Flaperon75]

JW411,

I disagree.

The incident under discussion did not occur due to a lack of hand flying skills. If anything the mishandling of the missed approach was caused by a lack of familiarity of how to use the automatics. The captain could have hand flown every exercise in every sim check for his whole career but that would not have prevented this incident.

At my airline we are encouraged to use the automatics as much as possible in any non-normal situation to free up capacity to manage the event and make the important decisions.

As others have already mentioned, the problem here was attributable to a lack of training/practice in a basic procedure i.e. 2 engine go around. Added to a certain amount of home base complaincency / lack of rigour (and what pilot can hand on heart say they have not been guilty of that from time to time).

[Cripes]

From an ATC point every time I've informed the following aircraft that the landing a/c may have hit a bird they have elected to put it down. At least give them the option. A mandatory go around seems a bit extreme.

[olster]

there is an alt button on the A380 FCU

[Flaperon75]

Ok... my mistake. Airbus single aisle have EXP button. Airbus twin aisle have ALT button. Learn something new every day :ok:

[Kirk out]

JW411, age 73, thank god.....

[helen-damnation]

Airbus single aisle have EXP button. Airbus twin aisle have ALT button. Learn something new every day

Me too :ok:

[tubby linton]

It is impossible to make sweeping statements about the fit of an Airbus autoflight system as there are now so many differences available to operators.The EXP feature is surpressed in many of the newer ones and the performance of the Push to Level Off feature of the Vertical Speed mode has led to problems in the past. My operator does not approve of its use.
Airbus now say on their Golden Rules card that if the automation is not behaving as expected do something about it, but working out what is wrong and then finding a correction can be difficult when tired.
It is quite easy to slip into former habits and behaviours in stressful situations and revert to inapproriate actions.
This was an early morning long duty. There is no mention in the report what time the pilots had awoken or how much sleep they had . I always find the first early morning difficult as your body does not want to go to bed early or be woken up when it really wants to be asleep. This,associated with the pressures the Captain had been experiencing due to the company restructure probably meant that he had less than a few hours of restful sleep. I have heard of pilots finding sleep very difficult in similar situations as they struggle to comprehend how they will deal with the sudden loss in pay and the inevitable changes in lifestyle for themselves and their families.As this sort of company reorganisation seems to be spreading across the industry in the UK I believe that there will be a lot of pilots who will empathise with this pilots predicament.

[dash6]

JW411. Thanks for the "history lesson" I was part of that history.I simply ask if any trainers think some of the simulator time could have been better utilised? And yes,"extra time" practice has been offered under assessment in one of my previous airlines,resulting in termination of training and early arrival at the bar.:)

[FlyingTinCans]

Two engine go around 101: Use one hand to Push and hold the thrust levers 3/4 of the way forward and use the other hand to pull and hold a pitch of 15 degrees.
Doesn't matter if it's a 747, A320, 737, 787, DHC8 or a 757 it works in all of them regardless of what modes/automation is engaged.

This didn't happen because of lack of training on aircraft type. This happened because of a lack of basic flying ability & airmanship

[Airbanda]

...... had been experiencing due to the company restructure probably meant that he had less than a few hours of restful sleep. I have heard of pilots finding sleep very difficult in similar situations as they struggle to comprehend how they will deal with the sudden loss in pay and the inevitable changes in lifestyle for themselves and their families.

Good observation I think and one airline managers should dwell on.

I'm not a pilot but have been through this restructure>change>relocation>poss job loss scenario several times. Even at an age and in a system where redundancy is a damn good deal I had plenty mornings of waking two or three hours early in a mental flat spin.

Being in same scenario at a time of life when mortgage and kid's education predominate AND early starts AND others lives depending on alertness puts my problem in perspective.

[misd-agin]

"This didn't happen because of lack of training on aircraft type. This happened because of a lack of basic flying ability & airmanship"




AAIB should add that to it's final report.

[Centaurus]

The incident under discussion did not occur due to a lack of hand flying skills.

I must respectfully disagree. It was lack of hand flying skills - and the commensurate lack of flight instrument scanning ability that resulted in the pilots inability to see the rapid speed increase which in turn caused the flap overspeed. At least the pilot manually pushed open the thrust levers to go-around power after inadvertently pressing the autothrottle disconnect switch and that was a plus. He then should have immediately disconnected the autopilot and manually pitched up into the GA attitude as soon as the airspeed was seen as rapidly accelerating down the glide slope as well as reducing power as needed to keep the airspeed increase under control. .

This is where manual flying skills come into play rapidly. Instead there were several attempts to get the automatic pilot engaged. Automation dependence strikes again. Why the blinding haste to re-engage the automatics? The real reason was lack of confidence in his own manual flying ability caused by years of automation dependence. It doesn't matter how expert a pilot is in the understanding and use of the automatics, it still takes a finite time for the automatics and thus the aircraft to react.

Often in the simulator we see pilots pressing the TOGA button and getting flustered if for some reason the thrust levers do not go forward. So what happens - well they keep on feverishly hitting the TOGA switch hoping a miracle will happen and the throttles will go up. In the meantime the airspeed steadily reduces...

How many times do we see in the simulator an instructor who demonstrates - repeat - demonstrates, how to seamlessly switch from an automatics type instrument approach to a manual approach with just three clicks of the AP, AT, turn off the FD and complete the approach manually. This should be normal competency. But it rarely happens because instructor demonstrations are a thing of the past. And more probably because the instructor himself lacks the skill or currency to do the demonstration. Yet the very basics of instructing include first demonstrate.

always thought that the old CAA Base Check/IR was a bit like the Seven Labours of Hercules but the new regime, in my opinion, was far too lax and seemed to me to be a recipe for concealing weaknesses that could have been put right with proper instruction and further training.
JW 411 nails it.

[ironbutt57]

Eckhard..I suspect you are referring to the "alt hold button"?..equivalent of "push to level" on the Airbus...by pushing in the VS/FPA selector

[McNugget]

Crikey,

I'm astounded at the number of people trying to mitigate what a total cluster this was. Yes, I know that its fashionable in aviation not to point fingers and apportion blame. I also know that we need not throw stones, willy-nilly, for 'it could happen to you' when circumstances conspire to paint you into a corner.

However, this was not being painted into a corner. This was a two-engined go-around. A beautifully simple operation in a Boeing. It is akin to being unable to do other very basic manoeuvres, such as landings, steep turns, etc.

Absolute lunacy that leeway is given over creating such a mess over something so simple. I appreciate that external factors may be impinging his critical thinking abilities, but the captain must have been legally unfit for duty sometime before such effects impinged upon his abilities to perform a go-around, and cause an emergency situation, whilst damaging an aircraft.

[ManaAdaSystem]

Absolute lunacy that leeway is given over creating such a mess over something so simple.

This incident should serve as a reminder of how fast things can go tits up in any cockpit. A simple error and everything cascades out of control.
Add limited fuel to put the pressure on, and you will find it hard to take a step back to catch your breath.

[McNugget]

That's true enough, we all know it, but there isn't much you can do with that information - except, topically, recognising that what you're after is THR/TOGA/TOGA, and not *blank/LOC/GS. Or else, things will go tits up, quickly.

The fuel concern came about due to the ineptitude of the crew. One could have argued that pointing your nose at an alternate and getting there ASAP was handling the fuel situation well, until you then cringe as you read further, whereby it is stated that NCL is long enough for a flapless approach.

How do you not know this about your home field?

I'm not disagreeing with what you say, Mana; but I'm afraid that it's hard to mitigate why this guy was near a commercial airliner when his mind is in such a state that he was unable to execute a MAP, nor correct his errors in a timely manner.

[planoramix]

JW 411, McNugget and Centaurus

thanks for your clear and accurate posts. You nailed the issue!
:ok:

[beardy]

but I'm afraid that it's hard to mitigate why this guy was near a commercial airliner when his mind is in such a state that he was unable to execute a MAP, nor correct his errors in a timely manner.

That is the real crux of the matter. This was a manoeuvre he had been shown, had practiced and could do. This time he didn't, not because he couldn't but because his mind, like yours and mine, has a limited capacity. His was filled with extraneous material generated by his social circumstances caused by company decisions.

[misd-agin]

Boeing's aren't that tough if you get automation confusion. You can hand fly it very easily and very quickly. If you desire to get back onto automation it is also easily accomplished no matter how screwed up the level of automation(FMA displays) is -


click, click = A/P OFF, A/T's OFF.


FD's - both OFF
FD's - both ON




You're in basic automation level. If you can't figure THIS situation out you have no business being in the cockpit -


Select roll and pitch mode as desired. Since you've been screwed up maybe


HDG - select


and


V/S - 1000' would be simplest.




A/T's - Speed






Obviously verifying the FMA's to see that the automation is actually delivering the desired thrust/roll/pitch mode.

[eckhard]

ironbutt57 Eckhard..I suspect you are referring to the "alt hold button"?..equivalent of "push to level" on the Airbus...by pushing in the VS/FPA selector

As far as I know:

Boeing MCP: ALT button will stop climb or descent and level at the altitude that the button was pressed. In other words, an overshoot and then regaining of the altitude.

Airbus FCU: push to level off feature of VS knob has similar effect except the climb descent will stop at whichever altitude is reached when VS is 0. In other words, no regaining of the altitude when the button was pushed.

Airbus FCU: A320 family may have an ALT button or an EXP button mounted in the same space on the panel.
Don't know how the ALT button works as my A319/320/321s don't have it.
EXP button works as previously described.

In my original post I was trying to point out that not all Airbii have an ALT button, although some do. I was answering a previous post which suggested that none had the ALT button.

Confused? I am!

[de facto]

click, click = A/P OFF, A/T's OFF.

My fo today went click click click click click click click and that was just for the autothrottle:}:p

[dingy737]

1. Impossible to rule out the human factor effect on the impending demotion. Who would call in sick for feeling demotivated for that? Can you bring your A game under those conditions? Depends on your personality?


2. Small events were taking them out of their comfort zone with each one slowing the brains ability to process information as some brain cells remained stuck asking the question "why did that occur I don't understand"?
a. Negative windshear of 15 knots .
b. failure to capture ILS [LOC] on first attempt.
c. Bird strike report. Go Around!
[First mistake disconnecting auto thrust instead of pressing TOGA no bigee. average pilot bad day at the office has happened endless times in the past and will happen endless times in the future]
d. Attempting to look beyond the flight director during go around.
e. Initial missed approach altitude just 1000 feet above.


3. The Herald report leaves some good points out from the official report
a. The captain said he reverted to "Airbus Mode".
b. The captain admits to thinking of the disciplinary measures for screwing it up while still reading checklist with a lot of work still ahead.
c. Co Pilot was unable to "open" the speed window and set the requested speed.{ can anyone shed light on this}Co Pilot admits to feeling agitated and dejected by what occurred when he started the leading edge checklist.
d. The autopilot repeatedly tripped out.
e.LE slat disagree
f.TE flap disagree
g. Low fuel for diversion
h. fuel pump low pressure light.
I. Fuel imbalance annunciation. [WHY?]
J. the co pilot could not program the fmc for the diversion in "rte 1" and after several attempts had to enter it in "rte 2" or alternate"
K.. Which diversion airport and runway length considerations


You can decide where, but at some point they were fully loaded and that caused everything to go downhill as it will for many crews. If you join the action at about 2000 feet in the missed approach and disregard how they got there for arguments sake, they got it together landed safely and I know several crews flying all over this planet that would have screwed it up far worse from that point onwards.
So many great lessons to learn here
Number one don't get complacent! When you least expect it, Wham its your turn up to bat!

[Max Angle]

you will find it hard to take a step back to catch your breath.
Number one don't get complacent! When you least expect it, Wham its your turn up to bat!

The two wisest sentences in this thread.

[Herod]

I think we have to look more closely at the human factors in this incident. I suffered a nervous breakdown in the air, to the degree that I was effectively a passenger in the LHS while the FO stuffed up an approach. No harm was done, and we landed safely. I hadn't realised what had happened until I saw the FDR readout, at which point I fell apart, and haven't flown since (ten years now). It's only by sheer chance that nothing worse happened; I was a ticking bomb. The cause? Stress, overwork, fatigue. All the things we don't think we suffer from, and the regulators can't (won't?) do anything about.

[deptrai]

Hard to argue with Herod here. I concur. I've felt I've been close enough to similar situations.

[macdo]

As it was explained to me the EXP button gave climb at Green Dot and Descent at MMo or Vne, this led to several alpha prot or high speed excursions. It was banned from use in our airline before I joined in 2000. Since then, all of our old narrow bodies have been retired and all the new ones have the ALT button instead. All wide bodies, I understand, have ALT button, which has the same function as pushing the VS button. I have also read somewhere that EZY had an incident years ago where someone pushed EXP insted of APPR, which must have caused a bit of excitement.
As regards the thread topic, there but for the grace of God.............
With regards to sim training, IMHO, it has been become more TRAINING and less TESTING, these days I come away from nearly every sim having learnt something new, in the old days I came away from a sim with a huge sigh of relief. Lets not revisit the past, but with the amount we are expected to cover in each detail, maybe more time in the sim for all of us would be beneficial.

[RAT 5]

Back to Basics: I admit I'm an old fart. I learnt to fly on old basic aircraft from GA singles & twins onto biz-jets and B732's. An excellent grounding: and every new pilot should have one.
I/we learnt to fly the a/c and use what ever very basic automation was available to achieve the task, plus motor skills. The basics of a G/round were to convert an approach (descent) into a G/A (climb); reduce the drag and accelerate. Now for a pilot who understands the a/c and its systems and capabilities that is not rocket science.
Over a few good many years I graduated onto these new whizz-bang VNAV LNAV beasts and found them a delight. But never forgot the old techniques. The FD & CDU are a tool; They are not my boss. If it helps then I'll use their information, but I'll decide. There is enough tertiary information to make that judgement, if you've been taught correctly.
Now, for a good (too) many years I've been teaching cadets to fly these even more modern whizz-bang thingies. Now they have SOP procedures coming out of every orifice. They do not understand how to manipulate the a/c, via hands, (FD), CDU or MCP to achieve the required task. They do not think, First? " what do want to achieve?" They first think, " what is the written SOP?" If they become confused due to pressure, loss of memory, panic, confusion, they do not have a basic understanding of 'what do I want to achieve, and how to accomplish it safely.'
If they did they could then operate the a/c within the confines of its design, achieve what is required and sort out the rest later on. As they catch up with the manoeuvre they can slot back into the SOP routine.
Todays teaching is not how to control the a/c in all modes and be in command of this race horse; it is how to operate according to SOP's and nothing else. It's trained monkey and a disaster waiting to happen.
On a good day SOP's will be fine and dandy. On a bad day you need full understanding of the beast you are riding. Pull the wrong reign and you are tipped off. Push the wrong heel at the wrong time and you are over the neck.
When will pilots be trained to control and command their beasts by basic knowledge? Sooner rather than smoking holes later.

[Shaman]

First mistake disconnecting auto thrust instead of pressing TOGA

and I have done the reverse twice on a 737 - pressing TOGA at 300' instead of disconnecting the authrottle and, to compound matters, pressing TOGA a second time being convinced that what I had successfully done was to disconnect the autothrottle. Result - 2 go arounds...

[Aluminium shuffler]

I have done it twice on the line, pressing TOGA instead of AT disconnect, but the mistake is obvious and easy to correct. I have also done it the other way twice in the sim on single engine go-rounds, flying accurately enough because I tend to look through the FD anyway, using it more to confirm attitudes than to lead me, but didn't consciously recognise the mistake or even that the FD was sill in APP! Those who haven't made that mistake will. A total of four occurrences in 16 years is not atypical, from what I have seen, but having the FD in APP while believing it to be in TOGA could create quite a level of confusion. FMA cross checking helps, but you don't have the opportunity to do that as you press TOGA because you're too focused on the pitch and thrust inputs, config changes and getting away from the ground.

[Agaricus bisporus]

It is all very well treating this as though it were just one mistake, a poorly executed g/a, but it wasn't. It was an appalling series of basic blunders and fundamental errors that began with the failure to cope with a cocked up g/a and showed a crews far behind the aeroplane they were unable to recover from one mistake

Any of us might foul up a g/a (worrying as that is in itself) but the knock-on failures that cascaded on from this original incident is surely proof that the crew simply weren't up to the job. Excuses of pressure, base changes arc are utterly irrelevant, it is the Captain's job to retain Captaincy and both of them to retain competency, all of which they manifestly failed to do.

This is a classic case of insufficient competency, clusterf*ck brought about by a single simple error. A crew unable to recover from a simple error like a botched g/a has no business in the business. Sorry, blunt as it is, its the reality. It's also not just an abject failure in technical skills, the highly questionable decision to divert without proper consideration of landing distances required shows an inability to apply reason to the situation too. = total overload - the one drop extra that caused all the water to fall out of the sponge.

You have to wonder at the competency of a crew that can't do a simple non urgent 2 engine g/a , but one that can't cope in all that comes after after this goes awry is way, way out of line.

No excuses for this sort of thing, and everything to do with lack of basic flying skills. Even if after 1400hrs on type (ffs!!) the 13000hr ,guy can't see what his FMAs are telling him he must, MUST be able to pickle the whole shebang and revert to first principles, surely?

But if not...

[Piltdown Man]

So what should be do with this crew then AG? And what should we do with anyone else who doesn't come up to your standards? How will we choose who gets the chop? How will we stop crews practicing for their "chop rides" in the real aircraft with passengers (like people used to do when we could all fly better)? And how many of your colleagues will be looking for new jobs? And when we start assessing other aspects, maybe the non-flying elements of our job, will you be up to it?

This is an example of a crew who got it wrong after having got up in the WOCL and who had been on duty for just over 11 hours, executing a manoeuvre they will have hardly ever practiced or done in real life (I'm lucky, I've done quite a few in the recent past for a whole variety of reasons - usually me). Unfortunately for this crew, after getting the initial action wrong, the rest of the flight continued in a similar vein. The crew were then frustrated because the aircraft appeared to fight them, preventing them from being able to get back in the loop. And let's remember, the captain knew he fouled up the G/A and imagined the consequences (looming internal demotion). Not the best frame of mind to start dealing with a problem, even if it was of your own making.

So what would have helped? Firstly, regular training to do a standard, two engine go-around. I don't think I've done more than ten in 20 years in the sim. In the real thing I've fouled up two - both of which caught me unawares, which is no excuse but I'm sure practice would have helped. But recently, I've being doing rather a few yet I'd still like more practice. But for this crew, once it started going wrong, they had no tool to do the aeronautical equivalent of stopping the world. It just snowballed... There has to be something that would work for a B757 to give a crew 5 -10 seconds of breathing space.

Lastly, this crew is not unique. There are many, many crews like these and the same initial go-around fiasco is highly likely. The same outcome though, is probably less likely. Our training, both in the manually flown past with the ex-airforce choppers and the modern, CRM orientated, mainly autopilot present has many useful bits missing. It's just damn shame that this AAIB report, with 20-20 hindsight, only told us that they crew didn't get it right. And had they done what they should have, then this incident wouldn't have happened. Gosh! What insight. Maybe it was written by the office junior. It wasn't up to their normal standard. A little guidance might have been useful or even some hazard identification.


PS. Their company's internal report does appear to show that TCX has a future because it looks like they understood what happened and that is where you start fixing the real problem.

[gtseraf]

had a brief scan through this whole thread.

No mention has been made of the time this event occurred. If they were at the end of an all night flight, I wonder how much fatigue may have contributed to this event.

Stress and fatigue are all too often ignored .

[tom775257]

I've also seen a two engine GA completely screwed up on an A320 (of which I was a participant and had to take control from the captain), a cabin crew member asked me afterwards 'were we about to die'. All from a perfectly serviceable aircraft in good weather performing a simple G/A just below missed approach altitude.

I think it would be good to throw in a few G/A calls in sims both above and slightly below missed approach altitude.

[JammedStab]

I had to do a go-around during my initial training on a similar type due to an unstable approach. Was new to the advanced aircraft type and during the missed we started getting new altitudes and headings(instead of the nice easy and briefed LNAV and VNAV button pushes at the appropriate times). The VS is very high and the new altitude is approaching fast, and there are lots of dimly lit buttons on the MCP that require pushing quickly and properly. I knew I would screw that up and am glad that I disengaged the automatics and handflew with a brief two hundred foot altitude deviation which I think was within limits.

Sometimes you just have to realize that you are not good enough to handle this stuff and try something different. Since then, I do try to review various go-around actions once in a while because I know it can easily be screwed up. A quick brief of go-around actions including hand movements can be useful to ensuring the right button bets pushed.

I also found myself forgetting to push TOGA during manual go-arounds in the sim. So I have added that to my go-around call to make it more likely that it wont get missed. Not SOP but it can be said silently. "Go-around" TOGA "Flaps___". Or just say it all in a real life go around.

[McNugget]

Agree with your last post, Tom.

Not in any way absolving the crew from their total responsibility for this cock-up, but you're right. G/As on the line rarely happen as per the 'brochure' (at minima). I personally have a couple of 'gates' around the missed approach altitude, through which I determine what AFDS modes other than TO/GA to use.

[Airbanda]

No mention has been made of the time this event occurred. If they were at the end of an all night flight, I wonder how much fatigue may have contributed to this event.

The AAIB report states the incident happened at 16:10 UTC (so 17:10 local) after a return flight to the Canaries from Newcastle. Mid August so daylight. Weather reasonably benign.

Arguably, the situation began to develop before the G/A when the crew failed to capture the ILS localiser at first attempt. As a non pilot it's not 100% clear to me why, but the report suggests high speed was a factor - perhaps they should have had a few more track miles to lose the excess knots?

For whatever reason the Captain was, from that point on, developing a thought that there was something wrong with the aircraft.

Was that the first 'hole in the cheese'?

[beardy]

G/As on the line rarely happen as per the 'brochure' (at minima).

A justifying observation:

Engine failures rarely happen nowadays, when they do it is rarely just before or after V1. Yet we always practice just that (some more enlightened companies also throw them in at other times.)

[Jwscud]

For those of you who don't do them with regularity, a day to the Canaries from Scotland or the North of the UK is significantly longer duty hours and more flying time than an East Coast sector. It involves probably a 4am alarm, nearly 5 hours sat on your backside, sometimes sporty Canaries approach, all of a sudden, rapid turnaround on the ground, then 5 hours home. If it's your first day on earlies as someone else mentioned you are probably bushed as you didn't sleep that well. Do TCX have a controlled rest policy? If not, did either crew member have a nap in flight anyway?

All information I would rather the AAIB had developed. I am always very careful when driving home after a day like that at the end of a block of duty. Some like them as they're easy money, but I would much rather a shorter or busier day. They really aren't any fun in the winter when after taking off in the dark, you again have to land at night in typically Scottish wind and rain.

[RAT 5]

Engine failures rarely happen nowadays, when they do it is rarely just before or after V1. Yet we always practice just that (some more enlightened companies also throw them in at other times.)

Time for XAA's to rethink their mandatory items. An engine failure before V2. I had one given to me at Go Round from an NPA. The G/A flap setting = V2 Vref, so this was deemed as to comply. It was an excellent opportunity to hone some skills. The surprise factor alone was worth a great deal. Even just at V2 on a takeoff as the gear is selected up. Both are bird strike territory and thus realistic. Between V1 & Vr is really a very small deal. There's no roll. At 50' you have to be sharp, just as the pax expect.

I go back to my basic point a few posts ago. Pilots should learn and be taught in-depth how to control the a/c and make it do what they want; by either manual raw data, manual with AFDS help or use of the MCP and automatics. They should then be allowed to use what ever system is available to achieve the required task as decided by the PF. I've flown for various airlines who all tried to re-invent the wheel. The SOP's all had various personal (CP) tweaks. The a/c were all built the same, all had the same kit, but were treated slightly differently. If in the moment of stress I was hesitant about my accurate memory of the current SOP I reverted to flying the a/c in a basic manner to achieve the task. That's because I understood and knew how to do it. Some people here say that a G/A from height with only a few 100' to level off is hard. Not it's not if you understand the a/c. I once flew B767 with an F/O who was making a teardrop outbound to turn in on an NDB. It was timed outbound with no DME; at night CAVOK with PAPI. It was a descending manoeuvre; no big deal. The MAA was 2500'. AT 1000' on finals it was obvious he was hot & high. Nothing was happening; he was fixated, so I suggested a G/A. At which point he slammed on full thrust and we rocketed skywards. With some exasperated coaching he managed to regain control of the V/S. The idea had been to retract to mid-flap setting fly a visual circuit at MAA and try again. On later discussion about how we ended up in that state his reply was, "you called Go Round, so I did what was normal." A B767 at light weight and full power is a rocket ship.
The other often heard claim about chaos waiting in the wings is a Go Round when above MAA. Agh! Disaster waiting to happen, we hear. There have been other calm voices on here whose first reaction would be to take a deep breath.
Good thinking, Batman. Then use the controls & AFDS as necessary to achieve the task required in a calm manner. Having confidence in understanding the /c and systems allows this. That is more important than practice. Practice is too often trained monkey repetition.
I flew with one company that insisted a G/A be completed 100% and then a re-brief made for the next attempt, even on a visual CAVOK day. It was not allowed, as was ably demonstrated one day by another airline, to climb out, retract flaps to a mid-setting, turn downwind into a visual circuit and land: all the while staying on tower frequency. Thus the G/A involved climbing up to a high altitude, changing to approach at another airfield, return to the beacon and start all over again. Thus, crews knew only one method of doing a Go Round. This was what was written down; they did not know, or have discretion, to use the necessary to achieve task efficiently and expeditiously.
So, when the G/A is commenced from an unfamiliar point they are lost. Sad days.

[Capn Bloggs]

Another outstanding post, Rat. :D
Then use the controls & AFDS as necessary to achieve the task required in a calm manner. Having confidence in understanding the /c and systems allows this. That is more important than practice. Practice is too often trained monkey repetition.

I'd say that the confidence you talk of is created by practising; that's why we're all so good at engine failures at V1. The problem is, where do you get the time. "Preferred" to use full automation, even flying around in VS and HDG frightens some, let alone the various scenarios for "go Rounds" or should they be "discontinued approaches" from a bit higher up...

In the Sim, "Can I..." "Sorry, no time". Or feel so knackered or annoyed you don't feel like it...

[WindSheer]

I am not here to criticize!!

Could this have stemmed from target fixation?
It is apparent from the report that the captain was concerned about the localiser capture issue, and referred to it for a little while after.
This could have been the single factor that led to the loss of situation awareness and the subsequent inability to regain it throughout the higher workload.

Target fixation is such a natural phenomenon, if you add extra factors such as stress it is so easy to completely lose SA.

An eventual safe outcome none the less by the crew and no-one hurt!!

[Centaurus]

Pilots should learn and be taught in-depth how to control the a/c and make it do what they want; by either manual raw data, manual with AFDS help or use of the MCP and automatics.

Well put that man. Managements should frame that post and reflect on it. :ok:

[long final]

There should be criticism. If I had made those mistakes I would want to be criticised. I have a job to do and responsibility for peoples lives. When I screw things up I want to understand that and learn. The fact the P1 was facing a change in his career structure should have no impact on his performance. Call it professionalism.

It happened and they screwed up. The issue for me is is this a one off or is there a real problem out there with basic airmanship. If two trained crew on a B757 for Thomas Cook can not manage the situation they were presented with that day would you want your wife and kids in the back? God help them if they had a real problem.

[RAT 5]

I'd say that the confidence you talk of is created by practising;

You're correct, Bloggs. Badly expressed. Practicing in the sim to tick a box every 3 years is what I might have been alluding to. It's the type of scenario that is thrown in as a recurrency exercise; "you've seen it now, so let's move on." The true practicing I was referring to was a/c manipulation, by whatever means, on a day to day basis. That is how I learnt, not in the sim. The variety of captains going into a variety of destinations showed a variety/spectrum of skills and techniques from which I and every other F/O learnt our trade. And especially from the mistakes, both from them and myself. Minor ones, of course, so we can still talk about them. The culture of the companies was to have good sound trustworthy capable pilots who knew how and what to do with their a/c in the whole spectrum of circumstances. Nowadays it is every pilot flies exactly the same way as written in the bible of that company and when circumstances shift them out of their comfort zone of the written word they are left floundering.
Now, if I was an a/c manufacturer, or AAIB/NTSB investigator called in after a pilot induced incident, I would be asking more questions than perhaps is the modern trend; i.e.what happened to cause the accident? I would go much further and ask "Why did they do that? Why didn't they realise and do something different? How did they get themselves into that predicament and why did they not know how to extricate themselves?" As a manufacturer I would expect type rated pilots to be able to handle the a/c, understand its limits and capabilities, and know how to use all its systems in all circumstances. I would not expect my design to cause confusion thus adding to the woes, or even creating them. I would be concerned and confused how my wonder toy could have behaved in such an adolescent and rebellious manner. I might then discover that the SOP's were very restrictive and that the training was strict adherence to those SOP's, no discretion, and that the box within which crews operated and were educated was tiny compared to the possibilities and safe capabilities of my design. i.e. yes, strict adherence to SOP's would have prevented the scenario developing, but because of various circumstances they did indeed find themselves in rough waters, but with sound knowledge and ability they should have been able prevent further worsening of the situation and re-eastablished stable control of the a/c, as my design was intended to do. I would ask the question why that had not happened.

[misd-agin]

Understanding, and realizing, when you need to move up, or down, the automation scale is important. And how to re-establish a basic automation level (both FD's off then on) and what mode that puts you into.


Several years ago the training department started added G/A's slightly above and slightly below GA altitude as set in the FMC and altitude on the MCP. It can quickly demonstrate basic weaknesses in automation understanding and/or basic flying skills.

[Piltdown Man]

RAT 5 - I wish I had written your last post. I, like you and many others, have been sold short by our current system and have tried to fill in the blanks by myself. I also fly an aircraft which I find nasty because of its (in my opinion) poor design. I also agree that the AAIB should have done more - the why, who, how etc. was noticeably absent.

[WindSheer]

Hmm interesting debate.

There is frequent reference to technical skills as the failings of this incident.
However, if you put this captain in the sim tomorrow and get him to fly the scenario again I am sure he will nail it.

However, could over learning something make it much easier to deal with from a non technical perspective - I have no doubt. Its so hard to set a training programme to absolutely nail everything though.......

[RAT 5]

Back to a solid grounding in the basics and a day to day operation that maintains those skills. This is not so simple as go to the sim, try it, and remember it incase it ever happens to you. You can not think of every scenario that the real world can throw at you and make a training program to cover them all. Impossible; but you can ensure your crews have a thorough grounding in a/c basics and should therefore be able to handle most scenarios. This thorough grounding can be encouraged in their daily routines and not discouraged as is often now the case.

[beardy]

This thorough grounding can be encouraged in their daily routines and not discouraged as is often now the case.

I am not entirely sure what you mean by this.

[Naali]

Reminds me something of...

[hambleoldboy]

The cause of this incident was the crew's incompetence in not checking or understanding their FMAs.

The FMA is the pilot's interface with the flight systems and must be anticipated, understood and acted upon.

It doesn't matter if manipulation mistakes are made, they can be picked up in the FMA.

I think it is true to say that with the exception of AA587 every Airbus that has crashed has been fully airworthy before impact. They all crashed because the pilots did not understand what the FMA was telling them.

The same might well be true of other manufacturers, and the Boeing 757 in particular.

[woodpecker]

Having spent 20+ years on a certain 3 engine, three crew aircraft where manual flying was encouraged I converted to the B757.

All of a sudden the emphasis was placed on using the automatics.. I remember one sim exercise being an ILS onto 14 at Zurich but with the wind 35 knots across the ILS approach was followed by a visual switch to land on 28.

The very junior training captain had us programming the FMC to fly the whole approach down to 500 feet including the visual switch on the autopilot. A total waste of simulator time.

The airline had the warning signs when someone almost stalled in the Bovingdon hold with the autothrottle disengaged. The response was to ban manual throttle, autothrottle had to be engaged at all times!!

Perhaps it all started with two crew, "your third pilot is the autopilot use it at all times" was the order of the day

[172_driver]

The cause of this incident was the crew's incompetence in not checking or understanding their FMAs.

It doesn't matter if manipulation mistakes are made, they can be picked up in the FMA.

I know the FMAs are important, it was emphasized from day 1 in school. But apart from that it bears little relevance to this incident. If you go down the ILS with throttles wide open it's not time to sit and think about the FMAs. Get the pitch+power sorted first. Then when brain capacity catches up you can re-activate automatics and ensure the FMAs are correct.

As numerous people have already pointed out.

[Mr Angry from Purley]

For those of you who don't do them with regularity, a day to the Canaries from Scotland or the North of the UK is significantly longer duty hours and more flying time than an East Coast sector. It involves probably a 4am alarm, nearly 5 hours sat on your backside, sometimes sporty Canaries approach, all of a sudden, rapid turnaround on the ground, then 5 hours home. If it's your first day on earlies as someone else mentioned you are probably bushed as you didn't sleep that well. Do TCX have a controlled rest policy? If not, did either crew member have a nap in flight anyway?

,
With his experience this flight should be bread and butter to a Charter Pilot.
Controlled rest - difficult in a B757 as the seat isn't made for it, headrest lack of.
The airline I work for puts it's new Commanders (upgrade) into a B757 and takes them up and fly go rounds from low decision height - I guess they have learned something

[framer]

In my mind there is an issue with how airlines are being run now days.
Rat5 said The culture of the companies was to have good sound trustworthy capable pilots who knew how and what to do with their a/c in the whole spectrum of circumstances.
My guess would be that the airlines Rat is thinking of were run by people who actually knew what it was like, and what is required, to be a capable pilot. They would have understood the feeling of confidence that comes with being relaxed and comfortable manipulating the aircraft well in different situations and also how critical that confidence is to achieving good outcomes. In most airlines today, the people at the head of training who often understand this don't have much power within the company so their inclinations are watered down and tempered by those above them who are more concerned with short term economics. The result of this is that passionate people leave the roles in fairly short order to be replaced by people who are less concerned with the watering down of their ideas and more concerned with the office they hold.
Here is a question; Has the time allocated to simulator training increased subsequent to the CAA's requirements for manoeuvre
based assessment of RVSM contingencies, TCAS resolutions, Low Viz Ops, PRM break-outs, and RNP-AR approaches?
If not, what has been left out to fit all this in?

[hec7or]

Q. what has been left out to fit all this in?

A. the flying

[tom775257]

Just a thought from my limited experience flying: With a procedure which involves the two crew to do something in a set order (and is very thoroughly trained as such)....where one action or phrase triggers the next and so on.. if this flow gets broken or an incorrect phrase or type reversion occurs; both pilots can end up confused. Training for type conversion or initial type seems very much along the lines of 'flows' and set actions rather than really thinking just about what you want to achieve. Obviously the SOPs should be sat on top of basic airmanship and type knowledge rather than blindly following the procedure.. but time is money.

[ZeBedie]

I find it totally unacceptable that ATC will order a G/A due to a dead bird/bunny on the runway. They should advise and let the crew make their own decision.

I guess the answer is a 'minimum fuel' pan call and ask to land anyway?

[Airbanda]

I find it totally unacceptable that ATC will order a G/A due to a dead bird/bunny on the runway. They should advise and let the crew make their own decision.

As mentioned up-thread it aint that simple.

What if the bunny corpse bounces off the nose wheel and gets sucked into an engine or the bird has flockmates swirling around the touch down zone?

[ZeBedie]

As mentioned up-thread it aint that simple.

What if the bunny corpse bounces off the nose wheel and gets sucked into an engine or the bird has flockmates swirling around the touch down zone?

I'm very relaxed about those slight risks. A bird/bunny strike on the landing roll will not hazard an aircraft. A bird strike on the G/A may well be a hazard, as may the resulting low fuel situation.

It's perverse to order a G/A due to a dead animal when every landing carries a fair risk that there'll be a live bird/fox/bunny on the runway. A live one is far more likely to end up in an engine than a flat one and even then, the risk is financial, not safety, unless you try to go-around into a flock.

[ROSUN]

I did the exact same flight two weeks previously. Aircraft went temporarily tech due to a leaky washroom. Two hour delay on take off turned into a 16 hour day. Knackered landing back at Newcastle? You betcha. Could I have done anything different? Yeah, loads. Did I want to get home that night ? Absolutely.

[Capn Bloggs]

Agree with ZeBedie; GA overkill for a non-theat. A dead cow or horse on the runway, yes but otherwise, pilot discretion.

The pilots decided to cruise at FL100 but the predicted burn was based on climbing to FL170.
Doesn't the UK require planning for contingencies eg depressurisation at any point in the flight?

[GlueBall]

Thankfully, I had learned from endless sim sessions not just to be prepared, but to EXPECT a go-around during EVERY approach.
This personal mind-set had developed many moons ago, thanks to one demanding sim instructor. His gig was to fail an engine 15 minutes into the first 2 hrs of the sim session, then we'd be motoring all maneuvers on 3 engines till the end. It was a high octane learning curve. :ooh:

[cossack]

Capn Bloggs wrote:
Agree with ZeBedie; GA overkill for a non-theat. A dead cow or horse on the runway, yes but otherwise, pilot discretion.
Discretion has been removed from ATC at many airports because the airport operator/owner of the runway has decreed it such.

AFR4590 at Paris was probably the starting point for such decrees and airport companies covering themselves against almost every threat, however small.

[helen-damnation]

then we'd be motoring all manoeuvres on 3 engines

Ah, the dreaded 3 engine GA:uhoh:

[Oakape]

It never ceases to amaze me how the 'blame everyone else but me' brigade thinks.

A crew stuffs up a go-around for a number of reasons, but hey, it's ATC's fault for sending them around!

It is immaterial why ATC sent them around. They did & that's it. The issue here is the poor handling of the go-around & what could be done to try to prevent a re-occurrence.

[lexxie747]

in stead of ordering a G/A by ATC, would it not be a better option to order a GO AWAY to the animal in question?
problem solved.

[Helen49]

Two different subjects being discussed.......animals/birds on airfields and what to do about them........flying the aeroplane following an unusual event.

What the two subjects have in common is the tendency towards using SOPs and the lack of freedom and to some extent the ability, to use discretion.

This problem starts at the airside gatewith the security guys and pervades the whole system right through to the flightdeck?

[ManaAdaSystem]

This may be a "bread and butter" run, but that doesn't make it any easier.
Why are we so fast in disregarding fatigue or tiredness?
I know how I feel after 13-14 hours. My performance feel like it is similar to what it would be after 2-3 pints. If I had a bad nights sleep before the flight and no nap in flight, I feel even worse.

What about subtle incapacitation?
When was the last time we got checked for signs of Alzheimer?
I have discussed this with our trainers. They admit we have pilots who fail or struggle in the sim, no matter how much they read and prepare. The information will not stick, and the affected pilots are quietly taken off the roster.
These (very few) guys would probably perform OK in normal ops, but would most likely struggle if anything out of the ordinary happened.

Now we can fly until 65, and they are working to remove that limit too.
The medical examination is still eyes, ears and heart. No brain.

[fireflybob]

Very little seems to have been said about the role the FO played in this incident.

I have said this previously but de facto this seems to be very much a case of subtle pilot incapacitation (or target fixation as others have mentioned).

The FO is the last line of defence in these situations.

I know it's a hard call for an FO to intervene but from the evidence presented he would have been quite justified in doing so.

[Landflap]

Excellent thread and very informative and useful discussion development. All agreed that the holes nearly lined up completely. I too am interested in the subsequent handling of the incident by TC. What happened to the pilots involved ? Also, why was the Loc overshot in the first place ? Loc armed ? App armed ? etc.

In perspective, might have been an isolated incident for TC. Big company and what have they done to safeguard a further lapse ?

Fully agree with all posters regarding the good ole days where we were trained to fly. Automation was introduced in stages and welcomed as an aid to off-load manual. But, if the autofunctions failed or complicated the issue, we just knocked it all out and handflew with absolutely no problems.

Differing management styles also have erased our handling skills. I can see the point. A bit. Discussion with a Chief Pilot led him to ask me to consider the fact that the company had invested very heavily in full automation in order to increase aircraft efficiency and, therefore, the philosophy was to encourage full use of that facility and to discourage handflying. I responded by asking him why then, did we have to demonstrate full handflying capability in the recurrent checks ? His response was that they allowed for degraded skills in the checks ! Not kidding. Good grief.

Same company, P2 handling, CAVOK, no wind, hardly any one else at the departure airfield. I asked him if he would like to handfly all the way to TOC for fun. He denied preferring to stick to company SOP. He later admitted that he doubted his ability to handfly to that level !

My submission is that we have allowed degradation in flying skills by sucking up to the Accountants. Twenty odd years later, here is the result. Near disasters all over the place in conditions that are hardly demanding.

JW411 : Well said. We Babyboomers might be scoffed at but we are around to tell the tale. I always announced the onset of non-normal check-list activity by a comforting, "I have the aeroplane, I have the radio". Trouble is, I think, Airbus and fly-by-wire technology is such that we never, really, have the aeroplane. It still has you ! Well, to a degree but the comfort level in automation remains high and attempts to resolve deteriorating situations through autopilot remains high for the new breed.

The TC Captain was hardly new but a Airbus Vet who referred to type. A trait that surely should have been looked for, even set-up for in his conversion to the Boeing. Mate of mine went the other way, Vet on Boeings and converted to Airbus. Every time he mentioned to the Instructors that "In the Boeing........." he was taken outside and roughed up.

[beardy]

Trouble is, I think, Airbus and fly-by-wire technology is such that we never, really, have the aeroplane. It still has you ! Well, to a degree but the comfort level in automation remains high and attempts to resolve deteriorating situations through autopilot remains high for the new breed.

It is no trouble. I have 40+ yrs flying, 20 yrs Airbus, 20 yrs military. I have confidence in the automatics, they allow me capacity to MANAGE the situation, hand flying decreases that capacity. Sure practice at hand flying limits the decrement, but it's still there. I still hand fly, but in low pressure situations; I encourage my FOs to do the same. I can only speak about Airbus automatics; they have to be understood properly and used with discipline, both requirements need study and practice. I would imagine it's like any other aircraft, certainly like any other I have flown in those respects.

[Piltdown Man]

Discretion has been removed from ATC at many airports because the airport operator/owner of the runway has decreed it such.

I fear you are correct. This also shows their complete and utter lack of foresight. I believe that it is correct for ATC to pass on relevant information at the appropriate time but to insist on a go-around following a possible birdstrike is reckless bordering criminal. Let us decide. Because if one these go-arounds goes wrong, where will the lawyers look? At us obviously, but also at the controller and the pathetic policy they were asked to follow - all beautifully recorded.

Fireflybob - It think it fairer if we look at the crew as a team of two rather than two individuals. As a team they failed to perform and part of the solution is to train as teams. In my own company I can think of many F/O's who might find this scenario challenging but can think of many more (the greater majority) who would normally be able to sort a situation like this out.

[fireflybob]

Fireflybob - It think it fairer if we look at the crew as a team of two rather than two individuals. As a team they failed to perform and part of the solution is to train as teams. In my own company I can think of many F/O's who might find this scenario challenging but can think of many more (the greater majority) who would normally be able to sort a situation like this out.


Piltdown Man, of course - for me that's a given. I wasn't meaning to imply otherwise.

But, to an extent, good teams need to have an effective leader.

Also I would suggest that in this case the FO intervening would have been a case of good teamwork.

[Oilhead]

Firefly bob has it quite right. Ultimately it was a team event and a team fail. But the Captain was the team leader and he failed at that too. He seemed to be just along for the ride and quite clearly had questionable competency issues for whatever reasons. I can't buy that a straightforward go around was so grossly mismanaged because it was of a "startle factor". On any approach you should be primed to go around, just as any take off you should be ready an emergency either side of V1. Complacency and competency are the greatest threats to ourselves. And it was the correct call by ATC.

[Fred Flange]

Some sharp cookies on this thread.

It's bleedin obvious that the pilots cocked up the GA and the resulting issues so well done for all the smart arse 'they were incompetent' posts, brilliant deduction Sherlock.

WHY did it happen?

Both pilots are experienced, have achieved at least minimum 'company standard' on every sim/line check but they still cocked it up. If it's a training issue then this company would have suffered with similar (although perhaps not as critical) cock ups but they don't.

The bottom line is the two pilots aren't usually incompetent so why were they on this particular day. Until that is answered then you or me or any of us could find ourselves in the same boat no matter how many times we've manually flown a raw data approach ffs!

[fireflybob]

When humans become "maxed out" (target fixation?) the first sense which the brain "deletes" is hearing.

In this situation the PM can say what he likes but the PF won't be aware of what he is saying.

A "pattern interrupt" is required in the form of a physical intervention e.g. shaking the PF on the shoulder and/or taking over control.

[long final]

Fred,

They didn't just cock up the GA around. They didn't manage a resulting simple problem. They flew poorly. They created additional warnings. They missed checklist items. The cocked up performance. They mis calculated fuel. They incorrectly managed fuel. They created a situation requiring a MayDay call. The landing sounded ok though.

I am always against the mob mentality here but this was not one error. There were two professional, trained crew there. I agree though the why and what next is the most important aspect.

[Fred Flange]

Indeed, that's what I said?

Why did two 'at least company standard' pilots become incompetent enough to make such a balls of it?

If it's training or over reliance on automation then is it just luck that there aren't more incidents?

If that's the case I'll just get myself a rabbits foot, a four leaf clover and a horse shoe for my flight case, that should do it.

[Uplinker]

Problem as I see it is the training and lack of practice of the manoeuver.

In the SIM, every 6 months, we do one all-engine GA, and one with failed critical engine(s).

That's usually it. We are expecting it* and it's usually flown 'near enough' for the tick in the box. If it is not, the instructor will say that they are just positioning you back to 4 miles to 'see it again' The second attempt will almost always be a pass.

However, the same 'competancy' applied to the end of a long day/night with low - but legal - fuel, and an unexpected* event in the real sky with real passengers (instead of a SIM in which you cannot die or even crash), can in some cases reveal shortcomings. The ATC Go-around command and the automation issue is a total red herring, but the type change in this case has relevance in that possibly the Commander reverted to previous type.

I think that critical manoeuvres such as this should be properly practised. Not just once or twice, but over and over, so it becomes a motor memory and refined and absolutely clear in the mind.

Otherwise, we are just going backwards. Despite all the lessons learnt by crashes over the years, we are taking less and less fuel, and less contingency fuel. And training is becoming less and less about basic flying and more about the latest SOP change or whim of the training departments. Training Captains often have so much new stuff to get through that there isn't time to make absolutely sure about pilot's basic skills, as long as they pass.

Also in the SIM, it is a very artificial environment. ATC is very restrained - you are the ONLY aircraft on frequency. There are no helicopters transiting the threshold ahead of you. PNF has not had to talk to company, or the handling agents. You have not been turned in tight or been left hot and high by ATC. You have not been told to keep the speed up or slow to minimum approach speed while they get one away ahead of you. You don't have the beep beep beep distraction of the cabin secure call. The visuals are usually not very good. I have never had rain or turbulence on approach in the SIM.

*Of course we should all expect the unexpected, but sometimes we don't. In view of this TC incident and my own experience, I am going to make an effort now to brief the actual go-around actions and selections, pitches, speeds etc that I will make in the event of a Go-around and those of the PNF, rather than just saying 'ahead to 3000 feet accelerate and then turn east' or whatever. I appeal to my fellow pilots not to glaze over when I do this, but to pay full attention.:ok:

(In case there is any confusion, I am nothing whatsoever to do with the incident under discussion !)

[piratepete]

Its really very simple.we all rarely do a go-around in line flying.if its an automatic/autopilot g/a it is extremely easy, however the main issue is when the a/p has been selected off then a g/a is required for some reason.the answer is to use a sensible (lower ) thrust setting than full g/a power during the early part of the g/a.on the 767 i fly full thrust is 1:47 epr, however manually setting a lower epr of about 1:30 epr will give you a manageable handling situation before you re-engage the automatics and everything will be comfortable.this is the key action.i have been a 757/767 tre since 1990 and am still active at it, works just fine and dandy, believe me.try it.

[Skyjob]

I am going to make an effort now to brief the actual go-around actions and selections, pitches, speeds etc that I will make in the event of a Go-around and those of the PNF, rather than just saying 'ahead to 3000 feet accelerate and then turn east' or whatever.

Standard SOP for us in company! Glad you think it's a good one...

[Uplinker]

It has been mentioned in ours too, but not in SOP's

But nobody actually does it !

[cossack]

Piltdown Man wrote:
This also shows their complete and utter lack of foresight. I believe that it is correct for ATC to pass on relevant information at the appropriate time but to insist on a go-around following a possible birdstrike is reckless bordering criminal. Let us decide. Because if one these go-arounds goes wrong, where will the lawyers look? At us obviously, but also at the controller and the pathetic policy they were asked to follow - all beautifully recorded.
Foresight is not used but hindsight is and now the lawyers are involved, unless every operator waives airport/ATC liability in the event of an incident, this is how it will stay. As I said earlier, here a "possible" strike would allow us to offer a discretionary landing. A "confirmed" strike would not.

In Ottawa, a crew lands long on a wet runway in an aircraft not equipped with reversers and runs off the end and their company sues the airport and ATC. Everyone is to blame except those directly responsible it seems.

Go-arounds are not uncommon, especially at high density airports, and we are continually told to try and reduce the number but not slow down the throughput of traffic. Figure that one out.

If a professional crew does not handle the go-around correctly because of reasons unknown (but heavily speculated) how is ATC to blame for initiating the go-around for whatever reason? We don't just randomly issue a go-around. We are following our rules and if pilot training is lacking or fatigue/stress/illness is found to be a factor, then things will have to change on the flight deck not in ATC.

[Uplinker]

If a professional crew does not handle the go-around correctly because of reasons unknown (but heavily speculated) how is ATC to blame for initiating the go-around for whatever reason? We don't just randomly issue a go-around. We are following our rules and if pilot training is lacking or fatigue/stress/illness is found to be a factor, then things will have to change on the flight deck not in ATC.

Absolutely correct, Cossack, well said.

[OBK!]

Poorly flown go around or not...it's what happened afterwards which was scary. Completely miss handled. I'd expect more from a PPL holder...yet here we have 2 ATPL holders. Tragic. Higher standards required in TCX maybe?

[Greek God]

Uplink & Cossack

Maybe not directly to blame but certainly another Link/slice of cheese to add to the sequence. Not that I disagree about the subsequent mishandled event.

[lurkio]

To me it seems a bit unreal blaming ATC for issuing a reasonable command to the crew. What if they had instructed them to go around at 250 agl instead of a lot further out and the initial part of the GA had been flown as badly.That would have got them very very close to terra firma. Doesn't bear thinking about does it?

[expat400]

FFS!

When I questioned the reason for the G/A I didn't blame ATC for this mishap. Two completely different issues but shouldn't we be able to discuss both?

[Uplinker]

Greek,

Yes; another hole in the cheese, but ATC are entirely justified if they see a need to order a go-around. If two pilots cannot handle such an order, then it is down to them and their training alone, NOT ATC.

As I say, (and you agree), SIM training has become so involved these days that basic flying skills are rarely, if ever, given sufficient practice time.

I mean, a concert violinist - or any professional musician - can, and often does practice every day. BA pilots can use their SIMs during down time, but how are most pilots supposed to keep their skills sharp when they do something just once or twice every 6 months?

[Flap62]

Surely both of these blokes will have done multiple two engined go-arounds while doing AWOPS in the Sim?

The fact that they both utterly failed to manage any aspect of the operation afterwards is something else. Just how bad do you have to be before the "everyone makes mistakes, they need re-training' mob will eventually see sense?

[RoyHudd]

Innumerable SOP changes, daily issue of contradictory Flight Crew Information Bulletins, over complex trapping sims, and forced demotions, base changes, and TYPE CHANGES. Put all these together, and create a blame culture presided over by outsiders, and what do you get????

Just a hypothesis folks, no finger-pointing. This scenario exists in a handful of UK airlines today. And doubtless MH, AF and others bear a close look too.

And as a secondary but relevant issue, UK ATC are issuing far more go-around orders than in previous years, with no comparable increase in traffic. I have experienced a couple of over-cautious GA orders in the last 6 months, at NCL. and MAN. We managed them fine, but were asking ourselves WTF? as we performed the manoeuvres and were actually quite annoyed about the whole things. (Human reactions) Has the defensive safety culture infected British ATC too? It really doesn't improve safety to be told to go-around for reasons that are more legally protective than practical. (This doesn't let the 757 folks off the hook, but it is a relevant part of the Swiss cheese model).

[TwoTone-7]

You could blame the pilots for not being able to fly, use airmanship etc etc but what would be the reasons for them to behave in such a way.

Personally don't believe the sim is where we are properly equipped to deal with such calamities properly. It is purely and simply what the other old timers have said. A typical airline has now become one which strives to satisfy the insurers requirements and needs. Training is all about ticking the box and manual flying is not only fully discouraged by disallowed to within a few hundred feet of a runway. Where, manual thrust control isn't allowed yet is a go item on MEL. What do you expect from all of this. No familiar with MPL but this full exacerbates the foundation of checklist flying.

It can happen to any of us and just like what happened here, at the end of a long day when we have the feeling of reaching home and dry, be bitten by something of this sort. What steps will the industry take in better equipping it's pilots (who are also not allowed to conduct private flying in their free time).

[Aluminium shuffler]

Roy Hudd and Two Tone 7, I wish we has a "like" button for posts like yours! As for companies hand flying policies, what is published in the manuals and what is pushed by local managers can differ wildly, and so many of our profession will toe the line drawn by their immediate superior rather than just do what they should. How extreme this problem is depends a lot on the individual pilot, manager and company.

[FANS]

Let's just blame the pilots and leave it there!! Come on guys!!

Was this not actually an issue about fuel, and a crew that were understandably in a somewhat concerned nature. Especially, as mentally 1 minute earlier they were probably thinking which exit would they use.

[framer]

Was this not actually an issue about fuel,
I don't think so. If I had to bet I would say it was an issue about stress levels reaching a stage where cognitive processing ability decreased markedly. The straw that breaks the camels back is just a straw. How else can we explain the pilot performing and passing many go around manoeuvres under examination yet in this instant....forgetting to press the correct button.
The real question is why did this guy not perform the way he has demonstrated that he can perform? Stress? Fatigue? Brain aneurism ?

[FANS]

I was getting at whether the fuel issue led to the stress levels. i.e. if they had 2 hours fuel, would it have been less panicked?

[Piltdown Man]

It is right and proper that in this incident we separate the (rather pointless) ATC initiated go-around from the actions of the crew. Because it is totally reasonable that ATC should expect us to be able to execute a go-around whenever they say. However, I think we are entitled to ask why go-around instructions are issued. But I don't think we'll get the real answer because managers with highly risk adverse parish council mentality have moved into ATC management. These people will whip out their safety flags, H & S credentials and "you can never be too careful" statements and attempt to bluster their way around the real issues. An example, although totally off this thread, is the quoting of "threshold elevation" on the ATIS of Scottish FIR airports. Someone has seriously lost the plot.

So Cossack - Can you tell me how safety is improved by ordering a go-around? Just because a procedure is written down it doesn't mean to say it has value. As someone has written earlier, a dead bird or bunny on the runway killed by the preceding aircraft will be one less for the following aircraft to bump into. Ingestion is just smoke-screening the real issue, backside covering pointless edicts from above. Tell us and let us decide.

Returning to the flying training issues:

Surely both of these blokes will have done multiple two engined go-arounds while doing AWOPS in the Sim?

Not necessarily and besides, you know it's coming. You will have prepared during the previous few weeks and rehearsed the words like an Shakespearean actor and delivered the required performance on the day. LOFT exercises in the SIM are also a 'hop through the hoops' jobs and for many, it's a "get out of the SIM ASAP". A colleague (who is also an instructor) I know once commented as he went into the main section housing the SIMs "Can you smell it?" "What?" asked our instructor. "Fear!" he said "The smell is leaking out from all of these moving boxes." And that sums it up. We are forced to deliver on time, on budget and failure to do so results an uncertain future - one that could have huge repercussions for you and your family. I'm lucky, I can handle it but there are many who can't.

It is fair to say we waste vast amounts of time pratting about with ridiculous scenarios. Ones that could be better handled in classrooms and/or procedure trainers. A better investment might be to spend some SIM time handling the second tier most likely to occur events or ones requiring complex handling procedures - two engine go-arounds, wave-offs, engine failures other than at V1, bird-strikes, lightning strikes, instrument failures etc. But having said that, our company's (re-current) type training programme is trying to do this and we are getting results. But we still have a long way to go but there are many companies who will have further to travel.

This TCX incident merely highlights the holes in our systems. Both our training and checking is deficient and needs looking at.

[Uplinker]

Well said, except we should all be able to execute a go-around whether ordered by ATC or not, so their involvement here is irrelevant.

FANS: I'm sure low fuel was a stress factor. Why do the CAA/ICAO allow us to carry such low fuel?

I have seen a real go-around handled badly. I know of a real EFATO where the gear wasn't brought up. These examples were both 'flown' by experienced captains, one of whom was a training captain.

As I suggest in post 143, perhaps we need to get back to the basics in the SIM and practice each manoeuvre say 10 times, not just once every 6 months.

A motor memory needs to be frequently practised otherwise it will fade.

[FANS]

But PM, how many pilots does your company dismiss each year on performance grounds?

[Piltdown Man]

FANS - Currently we dismiss very few, if any. Those who do require additional time will invariably get a little more than necessary, just to make sure. But I'll admit several years ago that was not perceived to be the case. Unfortunately, the bad taste still lingers on for those who remember that time.

[fireflybob]

FANS: I'm sure low fuel was a stress factor. Why do the CAA/ICAO allow us to carry such low fuel?

I have seen a real go-around handled badly. I know of a real EFATO where the gear wasn't brought up. These examples were both 'flown' by experienced captains, one of whom was a training captain.


In the days when we operated the B737-200 on the bucket and spade routes to the Canaries we were, more often than not, arriving at destination with minimum diversion fuel so there's nothing new in this and the go around was always manually flown.

Errors like omitting to retract the gear are usually caused by some form of distraction.

[FANS]

But isn't that the thing Bob, the skill and demands of operating a B737-200 regularly to its limitations are very different to those used to operating modern aircraft with automation.

[fireflybob]

But isn't that the thing Bob, the skill and demands of operating a B737-200 regularly to its limitations are very different to those used to operating modern aircraft with automation.

FANS, I know! I flew A320, B737-300/600/700/800 also - I made the remark for comparison - maybe we have gone backwards?

BUT I would argue that the basic skills required for safe operation have actually changed little, as this incident proves.

[FANS]

But do/did you find it much easier operating a 737NG/A320 compared to your B737-2?

[Landflap]

FANS, very good point and one too which I alluded to in earlier posts. Sorry JOHN SMITH, Post 137, can't agree."Two clicks and you have COMPLETE control in the same way as you would in any other aeroplane ". Nope. Two clicks and your side stick is still connected to FCC's that continue to talk to each other and protect you from any attempt at becoming a candidate for the Red Arrows. "Two clicks" and the thrust selectors (us babyboomers are used to "throttles") will give you whatever detent they are in with lots of protection. I don't think that is like any other aeroplane.

I flew thousands of hours on the 73/75/76 and if you disconnect autothrottle and autothrust and pull the control column fully back, THAT will be like ANY other aeroplane (except Airbus) and you will find yourself in the deepest poo imaginable.

The TC Skipper still looks to me like he reverted to type and even admits that he knew that he was supposed to be doing something with his thumb. All a bit too much wasn't it ? Airbus (?) sinch eh ? Click click, thrust selectors to that lovely , full forward detent(TOGA), everything taken care of. (Boeing, firewall the thrust levers after disconnecting autothrust and you are on your way to the best bar-b-q in town !

My contention is that years of protected flying on Airbus meant that our hapless TC Captain was still cuddled by a comfort zone that surrounds the new breeds of Airbus pilots which made him underperform with a handful of demanding aeroplane.

[fireflybob]

But do/did you find it much easier operating a 737NG/A320 compared to your B737-2?

I suppose anything is "easy" when you know how!

But I think the difference is that if you've been brought up on basic jets with round dials, a very basic autopilot and flight director, no auto throttle, no FMC etc over many years you become "hard wired" to confidently hand fly the machine through all flight regimes. You might be a bit rusty but you know you can do it.

Through no fault of their own we now have a generation of pilots who are not that confident about hand flying. This is a conundrum the industry has yet to solve.

And btw that does not mean I am luddite - I think automation is a useful tool to assist safe operation but it's the pilots that should be "running the show".

[FANS]

I suppose anything is "easy" when you know how

Very true, but it assumes you're capable in the first place.

I agree with your points about confidence and experience, but would also flag the capability point. In very crude terms, I do not consider whether all would be able to fly your 737-2 operations of yesteryear, albeit many will never have to today.

[beardy]

Landflap, it is seems that you don't understand Airbus, but have an opinion anyway. That's OK, but please call it your opinion, not fact.

If you want to be better informed in your opinion making there are some excellent, well balanced websites. There are also an awful lot of ignorant bigoted ones!

[cossack]

RoyHudd wrote:
UK ATC are issuing far more go-around orders than in previous years, with no comparable increase in traffic. I have experienced a couple of over-cautios GA orders in the last 6 months, at NCL. and MAN. We managed them fine, but were asking ourselves WTF? as we performed the manoeuvres and were actually quite annoyed about the whole things. (Human reactions) Has the defensive safety culture infected British ATC too? It really doesn't improve safety to be told to go-around for reasons that are more legally protective than practical. (This doesn't let the 757 folks off the hook, but it is a relevant part of the Swiss cheese model).
I no longer work in British ATC but did for 16 years and safety was and is still the main priority of controllers world wide. There are times we will let things run for as long as possible and other times you just know from early on that there's going to be a go around. We get no thanks for making a really tight situation work but get a whole lot of paperwork if it doesn't and we have done nothing to mitigate the situation. Those with less experience may not let things run as long as others, hence your perception of over-cautiousness.

Piltdon Man wrote:
Can you tell me how safety is improved by ordering a go-around? Just because a procedure is written down it doesn't mean to say it has value. As someone has written earlier, a dead bird or bunny on the runway killed by the preceding aircraft will be one less for the following aircraft to bump into. Ingestion is just smoke-screening the real issue, backside covering pointless edicts from above. Tell us and let us decide.
As I said earlier, there is some room for discretion and then there is no room for discretion.

If your approach is unstable but you get it back together at 450 feet (assuming you're aiming for 500 feet) should you be allowed the discretion to land? I'm thinking your rules say you have no discretion and you would have to go around. What would the ramifications be of you using your discretion here? Interview with no tea and biscuits?

We all have our rules and most of them are there for perfectly valid (to us) reasons and others seem asinine to us but we still follow them because they are perfectly valid to others: airport operators and their lawyers.

On several occasions I have had a routine, 4 hourly inspection take place and he finds FOD, be it dead birds, rabbits or bits of rubber crack sealant. Yes we've operated for up to 4 hours since it was last checked and nothing happened but the airport sees this as a problem and wants to inspect more often to cover themselves. If I know there to be something on the runway which may cause, however unlikely, an incident, it is in my duty of care to not let you use the runway.

[IcePack]

Trouble is today if you go-around you then you are on min diversion fuel. So if you want to land at the place you have just gone around at you have to commit to it & hopefully land above final reserve. So now who is taking on the duty of care ?

[The Ancient Geek]

We are seing more and more cases where minimum fuel was not enough for safe operation. Penny pinching airlines will always try to minimise weight by carrying the minimum legal fuel load so maybe it is time for the regulators to increase the legal minimum to a safer level.

[JW411]

And that is a very important observation. The way things are in modern day economics, if we arrive at NCL on absolute PLOG fuel and ATC order us to go around (because of a possible dead bird on the runway) then we must surely immediately divert to our declared alternate (in this case - Edinburgh).

The only other alternative is that we give up our ability to divert and stay in the hold at NCL in the hope that the airport authorities declare that the runway and absolutely everything else that might just possibly fall foul of HSI is absolutely free of the ebola virus, the tree- huggers, the Green Party and UKIP.

[TopBunk]

Cossack

If I know there to be something on the runway which may cause, however unlikely, an incident, it is in my duty of care to not let you use the runway.

One could argue that an alternative approach would be to advise the Pilot-in-Command that, for example, a dead small bird is on the runway centreline 500 metres from the threshold, and ask for his intentions with his aircraft.

That would CYA whilst providing the Captain with timely and useful information from which the best decision could be made.

Clearly if the obstruction is a dead cow/vehicle on runway it is a different matter.

[misd-agin]

A G/A isn't an emergency and shouldn't become one.


Power and pitch increase.
Flap reduction
PRGU.


That's the majority of the G/A in basic steps.


If the automation doesn't provide the correct response BE A PILOT. If you know the fix for the automation do it. If it's not obvious, OR if you're near the ground, or the autopilot or automation has produced an undesirable attitude or trend BE A PILOT. Fly the airplane. Since the automation isn't working as expected that leaves basic HAND FLYING.


Move up or down the automation level as necessary. If you're at a higher automation level and it's not going well, and if the fix isn't obvious or can't be accomplished immediately, get to a different automation level OR establish manual control.


This is automation/FMC/modern jet aircraft 101, isn't it?

[Discorde]

maybe it is time for the regulators to increase the legal minimum to a safer level.

. . . or to rescind the new FTLs to reduce the likelihood of fatigue. But they'll do neither until an accident is shown to be directly attributable to one of these factors.

[cossack]

Top Bunk wrote:
One could argue that an alternative approach would be to advise the Pilot-in-Command that, for example, a dead small bird is on the runway centreline 500 metres from the threshold, and ask for his intentions with his aircraft.

That would CYA whilst providing the Captain with timely and useful information from which the best decision could be made.

Clearly if the obstruction is a dead cow/vehicle on runway it is a different matter.
Indeed it would and in times past that is precisely what was done. Now our hands are tied by edicts from the airport operator covering their a$$es. If you want it how it was, its no good asking ATC, you need to speak with the airport.

[Uplinker]

Why is everyone giving ATC such a hard time on this?? The pilots :mad: up, not ATC.

Concorde crashed and burned because a small piece of metal from the engine reverser of the previous aircraft was left on the runway. Said small piece of metal burst a main tyre which smashed a fuel tank, which caused a fire, from which the very experienced French Concorde captain could not recover, although he did his best.

Who's to say the bird or bunny on the runway didn't go through the previous aircraft's undercarriage, breaking loose a brake line, or through the engine, liberating a turbine blade? So you land on that, and your tyre blows, and you run off the end. You would then all be saying "Why did ATC let us land when they knew something might have been on the runway and it should have had an inspection".

I ask again; why are the CAA/ICAO allowing us all to fly around on minimum fuel? This is an accident waiting to happen. A company jet landed at its alternate the other day with just 1400kg of fuel left in its tanks. It was legal, but was it sensible? Was it responsible?

[The Ancient Geek]

Taking a safe fuel load is the captain's responsibility.
It does, however, take some courage to stand up to the bullying management policies and their SOPs to demand more fuel than they think is necessary.

Should pilots be growing some balls or should the CAA be stepping in to regulate for more realistic legal minimums ?

Where is the problem, are todays pilots failing to ask for sensible contingency fuel or are the regulations inadequate.

[framer]

Should pilots be growing some balls or should the CAA be stepping in to regulate for more realistic legal minimums ?
That's an easy question to answer. If we could rely on consistently judicious fuel uplifts from captains and the appropriate dose of 'balls', we wouldn't need regulations at all. But we can't.
That is life, that is human nature.

[Piltdown Man]

I think fuel is an unnecessary diversion. The main topic here is the difference between what we think should gave happened and what actually did. Fuel might have been a participant in this incident but it was not. Their low fuel state was perceived as being beneficial because they believed they might be performing a flapless landing at MAN. The big issue is why, given the training and investment in this crew did it all go wrong? Will chopping these guys make the skies safer? Only if these two are the only rotten apples. But they are not. I think you'll find these two are not untypical. This was just an example and the next incident is there waiting to happen. When it does, the same usual suspects will hop up and shout (again) about poor flying and how people like this shouldn't be in the air. All the time ignoring the real underlying reasons that are responsible. The ones that live inside the totally fallible, but totally remarkable Mk 1 human being. Work on those issues and we start moving forwards.

[beardy]

Will chopping these guys make the skies safer? Only if these two are the only rotten apples. But they are not. I think you'll find these two are not untypical. This was just an example and the next incident is there waiting to happen.

Opinion or fact? If fact back it up please you have made quite an incendiary statement there.

FWIW I don't agree with you.

[slowjet]

BEARDY : Do cease trying to be a misplaced journalist and stick to thread. Opinion, rumour, fact, all part of this excellent forum and we are all fully entitled to express as we wish. Oh and Landflap needs no lessons. I agree with him that the Airbus is NOT like any other aeroplane. I too went from Boeing to Airbus and after a long night, offered a runway change at LHR . I accepted Right rather than Left, quite late, click, click, pointed the big bus where I wanted it to go with my sidestick & left thrust to do it's own thing. That, sir, is NOT like any other aeroplane & I went to the pub thinking, ' what a easy piece of kit this is'. Indeed, another mate of mine referred to the aircraft as "a gentleman's perambulator". Darn right.

[Discorde]

To summarise earlier posts: there are three main areas of concern for today's airline pilots (disregarding pay and working conditions):

- inadequate opportunities for practising handling skills
- inadequate min fuel requirements
- inadequate safeguards against fatigue

In the current profit-above-all-else business culture I doubt if any of these shortcomings will be addressed until a fatal accident forces revisiting the regulations.

[framer]

This was just an example and the next incident is there waiting to happen. When it does, the same usual suspects will hop up and shout (again) about poor flying and how people like this shouldn't be in the air. All the time ignoring the real underlying reasons that are responsible. The ones that live inside the totally fallible, but totally remarkable Mk 1 human being. Work on those issues and we start moving forwards.
That's it in a nutshell folks.
Put Piltdown man in charge of the CAA and pax will have to pay an extra 33 cents per sector but our skies will be safer.

[Piltdown Man]

Beardy - Which facts do you want backing up? I'll let history and just a small amount imagination do my job. If you spend your time looking back through published AAIB, NTSB and other governmental bodies' reports you'll see multiple incidents and accidents involving human factors. There are similarities and common threads running between them. Lack of perception, confusion, fright, invalid mental models etc. and so on all played their parts. Many steps have been taken to address these issues but we still have a long was to go - as this incident proves. The Mk.1 human being hasn't changed so we either adjust the environment (King Knut proved thus was difficult), the equipment (it's already in service) or the training and culture. Which is where I think I started.

[Piltdown Man]

Thanks Framer, but I'd prefer a couple of extra quid per sector. And we can spend this on training. Something that might save lives rather than the expensive theatre of security.

[framer]

I have to admit I pulled the 33 cents out of thin air but I was envisaging it being spent on training.
The thing is that if extra training was mandated, it would be done and the airlines would all pass the cost on to passengers and very few of them would cease to be consumers.

[beardy]

I'll let history and just a small amount imagination do my job.

Facts, not biased interpretation please. Unbiased, objective studies not self selected reports of when it goes wrong. What is happening when it goes right and what is the relationship, both as a fraction and causality between the two.

Do cease trying to be a misplaced journalist and stick to thread. Opinion, rumour, fact, all part of this excellent forum and we are all fully entitled to express as we wish.

I want to separate opinion and rumour from fact. Its not journalism its a scientific analytical approach devoid of emotion.

FYI I currently fly 4 different types, one of which is Airbus. "Click, click" and you have an aircraft which feels like a conventional aircraft with thrust levers that can supply thrust according to their position, as you should know. I am not sure Landflap is quite aware, from his comments he doesn't seem to be.

Much is made of whether their is an endemic handling problem and if it exists whether it contributed to this incident. I am not sure there is one, but I could be wrong and am willing to be proven wrong; repetition and shouting is not proof. I don't believe that the Airbus/Boeing debate has any place in this incident, each is different and each has it's own procedures neither of which was used in this incident.

This crew did not perform to the acceptable standards they had demonstrated in the past; they knew what to do, but didn't do it. Why has to be addressed. The starting point should be to confirm that the procedure had been taught and that they understood and had practiced it not too long ago for it to be no more than a distant memory. If that is confirmed (which I believe to be the case) then Human Factors need to be examined. Was the teaching adequate was practice recent? Was a Go Around briefed? If so, adequately? If all of that seems to be in order, what got in the way? Distraction? Fixation? Overload? Fatigue? Stress? I don't believe that these have been properly addressed, I do believe that they are important.

[Centaurus]

This A320 incident report from Australia reveals how easily the automatics can lead you into strife.

Investigation: AO-2013-159 - Stall warning event involving an Airbus A320, VH-VFJ, near Auckland Airport, New Zealand on 7 September 2013 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-159.aspx)

[Aluminium shuffler]

Fireflybob, while I agree to a point that the raw data and manual skills of the average old school guy are better than the average new guy because the old kit required those skills, while new aircraft are flown with the automatics and electronics plugged in, I also think you're comparing apples and oranges. Even within the 737 variants, operational, handling and instrument scanning complexities vary - I recently flew raw data manually on a 73-3 sim, despite not being in one for well over a decade, and it was a doddle, while the NG is much harder to hand fly and the scan is less efficient. When comparing completely different manufacturers and design ethos, rather than just a generations of the same type, then these issues are going the be enormous. I am one of those who believe that modern pilots' apparent decrease in basic skills are not just due to lack of practice in the old arts but also due to the poor design of modern aircraft with bad ergonomics and a contempt for handling characteristics; every effort is made to make the aircraft efficient, with seemingly no regard for how easy they are for the pilots to operate. The operation margins are being eroded from both ends.

[Pininstauld]

Checking the AAIB reports for October to read up the original report, it's interesting to see that juxtaposed next to the TC incident is this gem from Grand Cayman - defo worth a read if you agree with PM. The frequency of such events has been accelerating for many years - put simply, across the board, it seems as though we are gradually losing the ability to fly manually and simultaneously practise safe decision making. Could it be as simple as this?

We are not providing anything like sufficient opportunity to regularly practise manual flying skills, on line or in the sim.

http://www.aaib.gov.uk/cms_resources.cfm?file=/Boeing%20737-300%20VP-CKY%2010-14.pdf

[fireflybob]

The operation margins are being eroded from both ends.

Aluminium shuffler, Agreed - I see a convergence of several factors in our industry as this incident shows.

[Oilhead]

Staggeringly long day - I do not think that would be a legal assignment in the US. Fatigue could very easily have played a leading role in this unfortunate debacle. My brain certainly gets fried quite easily on a long duty day.

I was also amazed to see CAA recommend go round practice minimum of every 3 years. Are you kidding?! I expect to see 2 engine G/A's every time I am in the sim. I am far more likely to have to make an unplanned go around than see a post V1 engine failure.

And what was the company doing pulling the CVR to use on an "internal investigation" - before AAIB ramped it up.

I wonder what the working climate is like with management at this company? Sounds quite fraught to me.

[Mr Angry from Purley]

Staggeringly long day - I do not think that would be a legal assignment in the US. Fatigue could very easily have played a leading role in this unfortunate debacle. My brain certainly gets fried quite easily on a long duty day.


Oilhead - In the UK we're currently governed by time of day and number of sectors flown. On the assumption the crew checked in around 0700L the allowable Flying Duty in 12.15hrs.
Not sure if the F word is appropriate, maybe sleepiness. If we're looking at the F word we need to look at other area's,maybe commuting. The Airline the crews work for have a scheduling agreement which along with the regulations offer some protection against fatigue. The other area mentioned before was stress.

[Oakape]

This A320 incident report from Australia reveals how easily the automatics can lead you into strife.

From the report -

The crew resumed the approach, unaware that the auto-thrust system was disconnected, and therefore no longer controlling aircraft speed. As the aircraft continued to decelerate, soon after the final stage of flap was selected for landing, the Flight Management Guidance System generated a low energy warning. As the crew was responding to the low-energy warning, alpha-floor auto-thrust mode engaged. The crew accelerated the aircraft to approach speed using manual thrust control, and was able to continue the approach for an uneventful landing.

This is a common thread in a lot of recent accidents. Pilots seem to have the misconception that the auto-throttle system absolves them from monitoring airspeed. These guys were obviously not monitoring airspeed & the first indication that it was very low, was the low energy warning.

If you are monitoring airspeed (arguably part & parcel of flying the aircraft) you will notice if it drops below the required speed at any given time. You will then check that power is increased & that airspeed stabilizes. Non-moving thrust levers make that a little more difficult to do as you need to look at the engine instruments, where as with moving thrust levers you will feel them move under your hand. (You do have your hand on the thrust levers, don't you?!). Either way you will pick up a problem if thrust does not increase as speed falls below the bugged speed.

The problem these days seems to be over-reliance on the automation combined with a lack of complete understanding of how the automation works. The incident in this report backs that up.

[Capn Bloggs]

Pilots seem to have the misconception that the auto-throttle system absolves them from monitoring airspeed.
Rubbish. Pilots are subconsciously suckered into less monitoring by a system that works perfectly 99.9% of the time. That's why all these LOC accidents/incidents are occurring; pilots have been forced out of the loop. I'd be disappointed if you don't realise it's happening to you, right now, Oakape. And yes, I do realise that is our job, but the reality is...

[Oakape]

Rubbish. Pilots are subconsciously suckered into less monitoring by a system that works perfectly 99.9% of the time. That's why all these LOC accidents/incidents are occurring; pilots have been forced out of the loop. I'd be disappointed if you don't realise it's happening to you, right now, Oakape. And yes, I do realise that is our job, but the reality is...

If pilots are 'subconsciously suckered into less monitoring' it is because they are not trained correctly, or lazy, or unmotivated, or undisciplined or lacking in airmanship. Or a combination of all of those things.

The automatics are an AID, not a pilot. And any pilot who gives that level of control over to the automation will eventually find themselves in a bad place.

The pilot flys & the automation assists him/her in that task to reduced workload. The autopilot/auto-throttle system is not pilot #3, who can completely take over from you & allow you to completely focus your attention elsewhere.

The auto-throttle in my flight deck does not have any say in where it positions the thrust levers. I decide where they should be & if the auto-throttle is not smart enough to have put them there, I do it manually, by either over-riding temporarily or by disconnecting the auto-throttle all together.

The reality is that people have got lazy & think they can have a cool job where they don't have to pay attention or do any work. Lazy operation where the autopilot goes in shortly after gear up until fully configured & stable at 500' has led to this.

Pilots have not been forced out of the loop, they have willingly removed themselves from it & the automatics have simply allowed it to happen. It is human nature to enjoy the good times & not think about the future. To not concern themselves with the eventual degradation in skills, knowledge & ability. High levels of enthusiasm for the job will lead to the levels of discipline & airmanship required to ensure that this does not eventuate. Unfortunately enthusiasm is in short supply in the industry these days. The profession has been attacked in many ways over the years.

The final layer of protection is respect for the seriousness of the job. Operating complex equipment in a dynamic & challenging environment requires people to respect it, if it is to be accomplished safely. The problem here is that these days no one seems to have any respect for anything & certainly not their job.

As for 'rubbish', I will just have to disagree with you on that.

[Capn Bloggs]

So you reckon all these prangs where aeroplanes get away from the pilots are caused by slack-@rses who don't get a rat's anymore? Good one. As I say, rubbish.

[framer]

Oakape, I think what you said about a lack of respect for the seriousness of the job is quite important and is tied in with what I said in an earlier post about the top levels of management not understanding what it takes to be a skilled operator. Most top level airline management can't understand it because they have never been in charge of an airliner when a non-normal is playing out in nasty weather, they can imagine all they like but until you have held that responsibility you'l not completely understand the job.
The other comments you made about pilots wanting a 'cool job where they don't pay attention' is off the mark in my opinion. I, like yourself, understand the importance of controlling the thrust levers while I'm flying and will also often override them when the auto throttle is a bit slow to react, but I don't think all pilots are aware of the importance of being that ' integrated' with the flying of the machine......so why is that? You say it's because they are lazy or lack airmanship but I think it is because they simply don't understand that they need to continually use the brain circuitry responsible for these motor actions lest the circuits lose their myelin wrapping and fail to function when needed. As an industry we need to actively teach/train the importance of maintaining the circuitry, it's pretty simple really, the 777 into the sea wall would never have occurred if you were the PF so we need to make the average airline pilots brain more similar to yours by bolstering the appropriate circuits. How do we do that? Adding an hour of raw data circuits and approaches at the start of each sim as non assessed training would all but fix the problem I reckon, if it was mandated then all airlines would have to comply and the cost would simply pass to the passenger.

[Oakape]

Hi framer, from my post -

they are not trained correctly, or...... Or a combination of all of those things.

You will notice I said not trained correctly as well as including the other issues & also that there can be a combination of the various reasons.

The reality is that people have got lazy & think they can have a cool job

The word I left out was 'some' in front of people. I am not saying that every one is in this category, but I have come across more than my fair share of them over the years, particularly the recent years.


From your post -

You say it's because they are lazy or lack airmanship

No, I say that these are two of the reasons. Two that, among others, have no real excuse.

Lack of training is the real big issue here. Cost pressures have mean that we now have a situation where training is now cut down to a price, where it ideally should be built up to a standard. The back stop for this has always been the professional pride taken by the pilot workforce in general, that has individuals doing the extra curricular work & reading & study in order to reach the high standard that was required. A lot of pilots, both young & old still have this approach to the job, but I do feel I am seeing more & more of those who do not. The training departments don't seem to require it anymore & that may be largely a reflection of management attitude.

Being an airline pilot was something that most of those with an interest in, & a love of, aviation aspired to. These days it sometimes seems that not many hold the job in that high a regard. In some cases it is simply a case of a good return on investment over the years, coupled with the mind-set that they have a god given right to the job, while putting in as little work as possible.

Most people seem to believe that all pilots are adequately trained & are highly motivated to do the best that they possibly can when on the job. Maybe I'm just getting jaded, but unfortunately I just don't subscribe to that position anymore.

the 777 into the sea wall would never have occurred if you were the PF

Maybe, maybe not. I like to think not. However, I am just an average Joe & just as fallible as others. The thing is, my professional pride means I go to work each time with the intent of executing the perfect flight. I have never achieved it, but I still try. And I still get quite annoyed with myself over all the little errors & slips that occur. I still read as widely as I can & try to take lessons from all the accident reports that I manage to read. And I find it frustrating that as I age I get a little slower & make some silly mistakes on occasions. Mistakes that I would never have made in my younger years. So when I have a young guy sitting beside me who just doesn't give a damn, I get frustrated & annoyed. Frustrated & annoyed that he/she is not giving me the support that I should be able to expect; frustrated & annoyed that they seem to be more interested in one-up-manship than just doing their job; frustrated & annoyed that they put me & everyone on board at a slightly higher level of risk due to their attitude. And then I get concerned at just what the future holds for aviation.

It's not everyone by a long shot, but the percentage seems to be increasing as the years go by. Some of my flying buddies & I joke that when we retire we will only feel safe travelling by ship. That or just stay home. The trouble is that it is becoming less & less of a joke & more & more of a serious consideration.

[Oakape]

Yes, msbbarratt, I believe you. Perhaps by the time it comes for me to give the game away it will be better if I just stay home.

Perhaps it is a 21st century thing, not just an aviation thing. I was asking my wife just the other day 'when did near enough became good enough'. The quest for the almighty dollar seems to have become the mantra of these times & everything else is of secondary or no importance.

Management has a large responsibility here as well. It's not all the responsibility of the guy on the street. Like kids, they will follow the example of those above them, particularly if the rewards are perceived as being so great.

Anyway, perhaps that is enough philosophy for now.

[Uplinker]

These pilots who do not monitor the speed; what are they looking at on approach??

On the 777 and Airbus FBW family, the speed tape is right next to and on the same screen as the AI, so if pilots are not watching the speed tape then they cannot be watching the AI or the altitude tape either. WTF? As several have said, speed is a very basic parameter of the most fundamental airmanship.

A visual approach means that the tracking/navigation is done by looking out of the window, but a pilot still needs to regularly look at the other instruments to check speed, altitude, vertical speed, N1, etc.

Oakape; I mostly agree with you but I don't think most pilots are lazy or can't be bothered, it is simply that we seem to be entering a very dangerous training philosophy, where the latest SOP change or fuel saving initiative is taking preference in the SIM over the practising of motor skills.

Whoever just said that there should be an hour of manual flying practise at the beginning of a SIM without jeapordy is spot on! This is something I have said myself: Let each pilot do 5 EFATO's, 5 manually flown go arounds, and 5 go arounds using the automatics before anything else is done.

Take a musician's instrument away for 6 months and then give it back and ask them to play something complicated, and get it right first time with no practise. Would they be able to do that? Err, no. What do bands do before a tour? They book into a studio for a couple of weeks to rehearse all their material.

We can't practise go arounds on the line with passengers, but how about as well as us doing and recording a certain number of Autolands in every 6 month period, our training manager should require that we all do the same with manually flown, raw data approaches with no flight directors and manual thrust - obviously in appropriate conditions?

If nothing else, this might help keep our instrument scans and manual flying up to scratch.

[Centaurus]

Adding an hour of raw data circuits and approaches at the start of each sim as non assessed training would all but fix the problem I reckon,

Interesting angle and a very good idea. But why make it non-assessed training? Is it because most automation addicted pilots would make a real hash of raw data circuits and it may too embarrassing to record.:E

[calypso]

Unfortunately is not just laziness. Working days are much longer now than they used to be. At my outfit 12 hour 4 sector days with 30 minute turn arounds are the order of the day. AT the best of times you are knackered and keeping the automatics is sometimes a way to keep workload (and fatigue) down.

I personally do at least one full raw data, manual thrust approach every few days but I have to admit that after one of those I am more tired.

Fatigue and automation dependency feed of each other

[fireflybob]

Perversely flying a/c like the B737-200 there was more to keep you occupied which helped to keep you mentally awake.

Fatigue is an issue but is the relatively low level of alertness required in normal operations a double edged sword?

[hec7or]

centaurus writes

why make it non-assessed training?

I think people learn more when they are not being tested, you learn during the lesson and regurgitate what you have learned during the test.

It is not just pilots that have become over reliant on automation, ATC requires us to be RVSM and BRNAV/PRNAV compliant, companies need efficient FMC routings and profiles to be flown, safety departments require that we operate with EGPWS and WXRDR displayed alongside all the other distractions, all taking their own slice out of our mental capacity and situational awareness.

Prescriptive SOPs require us to make all the right calls and selections at the right moment, with no backup procedures to follow if the wrong button is pressed or the wrong callout made.

Flying the aircraft, free from all the above distraction is clearly what we should be doing more of during the recurrent training

[Encorebaby]

I was just reading and nodding my head to the many recent opinions here when I was reminded of my last sim. As part of the Routine schedule for that session we had to fly a visual circle to land in accordance with our company SOP ' S. I'm sure that ours are much the same as most and involve the usual elements of 45 degree angles and counting seconds in various directions whilst remembering to add on/take off degrees and seconds for wind not to mention remembering to descend at a given rate depending on height whilst using various flight director modes as a back up!! My somewhat convoluted point here is that, without disregarding the obvious dangers inherent with a procedure like this (as highlighted by accident numbers), it seems to me that our industry has totally over complicated this manoeuvre. I haven't even drawn attention to the circle to land mist approach procedure which, from any position after late down wind is ridiculously confusing (far more so than the Newcastle case of this thread).

We as pilots should all be able to fly a VISUAL circuit and perhaps even without over complicating it with numbers and angles. It is the first thing I learned in a C152. The whole idea is that one keeps an eye out of the window at the runway and flys the plane how ever big or complicated it may be. Perhaps this SOP over complication (and I realise that there must be a SOP) optimises the whole modern approach to our job. Too many words and procedures and not enough back to basics...

[fireflybob]

We as pilots should all be able to fly a VISUAL circuit and perhaps even without over complicating it with numbers and angles. It is the first thing I learned in a C152. The whole idea is that one keeps an eye out of the window at the runway and flys the plane how ever big or complicated it may be. Perhaps this SOP over complication (and I realise that there must be a SOP) optimises the whole modern approach to our job. Too many words and procedures and not enough back to basics...

A lot of this is down to the "blame culture".

If airlines spell out in minute detail how to do everything and the pilots screw it up then the managements can say "nothing to do with us mate - we told the pilots how to do it in the manuals".

SOPs are important to safe operation but sometimes you seem to spend more time trying to recall the latest instruction in the manual rather than applying common sense and airmanship.

Also there is a big difference between telling pilots "what" to do instead of teaching them "how" to do it.

[RAT 5]

Hooraah. B to B. Recurrent training is a sticking plaster on the wound caused by lack of basic training. I feel there needs to be an operation. IMHO it is where the root cause is; at the beginning. Obviously Encore is a modern pilot as he trained on a C152 and not a C150. (there are others who trained on a C130, and that is the biggest Cessna I've ever seen. I digress, sorry)
But it is true; us old farts were brought up on B732 & DC-9's etc. It was Mk.1 eyeball out the window with hand and feet on everything. We knew what parameters to set in power/attitude. We knew speed v distance v height = energy. We kew how to control the a/c to achieve the required task. Simple. KISS as much as possible. That was an SOP.
I still advocate the beginning of jet training should a continuance of flight school training on basic a/c. First learn to fly the basic a/c and then learn to operate and manage it. In modern jet training and MPL courses the emphasis is on the SOP MPL operation of the a/c and not how to fly it and make it do what you want in any given scenario. This could be via manual control or AFDS. Then, when you are caught by surprise with an unusual manoeuvre out of the blue you just do what is necessary using your knowledge. Yes, practice may be necessary, but that was a daily matter on B732. If you never had the knowledge in the first place then you had only the SOP manual to revert to. That is too often the case after a modern jet TQ course. That is not being a pilot in control of the situation. The SOP manual can not cover every eventuality.
I'm sure the Apollo 13 guys didn't have an SOP manual for their "up the creek" moment. There has been many an occasion when an SOP did not exist. Neil Williams's inverted approach with his wing folding up comes to mind. The Sioux City DC-10 and the latest Qantas A380, also. Sadly, there have been other avoidable smoking holes if the basics had been adhered to, but they had lost in the mashed pulp of 'operating automatic SOP's' which permeated through the TQ course.
2 sessions of basic flying; no FD no A/T just Mk.1 brain, hands & feet. Then add the AFDS, then the autopilot, then the NNC scenarios. Build the foundations first, solid, then the structure will not fall down at the first puff of wind. Add the curtains and furniture after the roof is on and windows closed.

[framer]

When I joined my company my type rating consisted of seven sessions plus a check ride. I commented that there was a lot to learn in the time available, the instructor told me he had watched it come down over the years from 14 sessions and a check. During this time new SOP's had been added that needed training. I'm not sure how many sessions new hires get now. So why did the number of sessions reduce? Is it because the calibre of recruits has steadily increased and less time is required to meet the airlines high standards? We all know that several non-pilots sat around a table and discussed how they can compete with the ever intensifying competition and decided their was some fat in the training department. The cuts were made, safety played second fiddle to competition, and the savings were passed on to Joe Public in the form of $39 one way fares to wherever.
Where does it stop? The way the system works it will only stop when legislation changes so that all companies are equally effected and the cost of training is passed on to Joe Public through a $41 one way fare to wherever. Until the regs change mandating certain basic flying training, it won't happen and we will see more and more instances of pilots unable to pilot as the skills leave the airline through retirement.
I think Rat5 that your idea of back to basics is part one of the solution, parts two three and four will be needed to ensure the skills remain.

[Uplinker]

Sadly it is all down to money, and ever lower ticket prices. WTF? Of course we should be taught to fly every aircraft manually and with raw data first, followed by a gradual feeding in of the automatics, but that would use up too much of the profits. And it's not the workers who are benefiting from this money saving. It is the owners or the shareholders who are fast asleep in bed, raking in the profits while you and I are mincing around doing our 4th sector in the middle of the night in bad weather, carrying MEL issues and delays. (Or flying to countries with Ebola). CAA/ICAO should be more pro-active in checking airlines for responsible engineering support, responsible training, responsible crew compliment, sensible SOP's, etc.

Meanwhile, the management think it's all fine because Johnny Newboy with their MPL can fly perfectly well using the automatics and the SOP's.

(I am not having a go at 'Johnny Newboy'. It's not their fault either).

[RAT 5]

It is the owners or the shareholders who are fast asleep in bed, raking in the profits while you and I are mincing around doing our 4th sector in the middle of the night in bad weather, carrying MEL issues and delays.

Meanwhile, the management think it's all fine because Johnny Newboy with their MPL can fly perfectly well using the automatics and the SOP's.

When training in 2 rapidly expanding and financially successful LoCo's we questioned the length & depth of the TQ training and general daily line operation philosophy. The reply was that the emphasis was on a successful growth of the company. Nothing wrong with that. The next comment was that SOP's had to be rigid and followed. The companies had not yet reached critical mass, i.e. they could not afford an accident. It would spell ruin. The only way was strict adherence to a simple SOP formula. Too many crews were out of sight all over the region. I understand very well the rational of this attitude. It has proved successful. Add to this that the students are paying for their training. Another 4 sim sessions in the TQ would be very expensive. The argument is that LT will put some meat on the bones; the intense sector flying will create a steep and fast learning curve; the modern technology/reliability will add a strong level of safety. It's a compelling argument, but when the holes start to line up perhaps more than the basic requirements are needed to close them off. Add to all that the level of experience on the modern short-haul captain and it can be discussed that safety levels have been trimmed to bare minimums. In days gone by the old fart in the LHS could put a calming hand on the trembling pulse. Not any more with only 3000/4 years experience sitting there. Hence the rigid, no discretion, SOP model. It seems to have worked in the majority of cases; it's when the untoward happens and it gets messy; that's when the weakness of this philosophy is exposed. However, making a risk assessment of this over all the short-haul sectors flown every day, what is the true level of the risk? It may be considered extremely minute and acceptable. As a purist I'd still prefer the more in depth training of basic piloting skills and more in depth training of use of the automatics. My first airline was started by pilots. The MD was a pilot and all the management were pilots. The pilot corps were real hands on operators. Now, there are very few, if any, large airlines who are managed by pilots. Indeed the opposite; I know of airlines where the first level in management where you find a pilot is C.P. Even the DFO is not an aviator. This explains how the culture is so driven by finance and not flying standards. Modern a/c are no longer machines to be flown; they are profit generating instruments and the crews, engineers, rosterers etc are a pain in the rear-end costs. Regulations are not helpful so they try and dilute those. If the job can be reduced to rigid following of rules as to when to press which button then who in management cares? But I still doubt we'll see a passenger pilotless a/c in my lifetime: well not one with pax on it. And those pax still expect us to save their bacon when necessary and not jeopardise it.
It is said that the skilful pilot is one who avoids situations where they need to use their skill to escape. That might be true, but then you need those skills to make that judgement. I fear that the general knowledge of many crews today is devoid of that skill base. If they then find themselves out of their comfort zone, and have not enough skill to fall back on, a bad hair day will ensue.

[Chorlton]

I think this is a very poorly titled thread & highlights the lack of professionalism in our industry today .

I know I've made many mistakes over the years , some I've got away with , others have bitten me hard.


It's very easy for us all to read a report like this & be astonished at the chain of events but I don't know one friend in the industry who hasn't driven home at leat once thinking theyve just got away with an event.


Thomas Cook strike me as a very professional outfit who will/have provided the correct back up training for the crew , end of discussion , it all lies in the training.


The job is changing , the move from manual flying to a smoother management of automated systems is a move in the right direction & is providing a better safer more situationally aware environment. The 'macho' must fly manual approach to fly properly really should be a thing of the past , good management of these highly efficient systems is a much better alternative to the poorly flown often uncomfortable manual approach & correctly flown will keep your scan as health as ever.


I think we should leave this crew alone & all discussions should be with your own training Dept's.

[Chronus]

Just read the AAIB report which basically amounts to a case of itchy finger trouble.

Well rested crew, all well outbound and all well until ATC rightly and properly calls for G/A shortly thereafter all goes for a ball of chalk and stress levels go exponential.

The only excuse a shrink comes up with is a Captain worried about impending demotion and that we all suffer with an itchy right thumb. I say, what would have happened if first officer was PF, would he have had an itchy left thumb. The RAF joke used to be Left and Right written on the white chami gloves. Should we now add A/T on the right thumb.

I am afraid whichever way one looks at this incident it is an inescapable conclusion that it was all down to the crew.

[Hotel Charlie]

The 'macho' must fly manual approach to fly properly really should be a thing of the past , good management of these highly efficient systems is a much better alternative to the poorly flown often uncomfortable manual approach & correctly flown will keep your scan as health as ever.

What a scary attitude! Automation is an excellent help but I'm never gonna be a slave to it! If you cannot fly a manual approach proficiently without calming to be macho you have no business calling yourself a professional pilot and definitely not an aviator! :rolleyes:

[RAT 5]

I think we should leave this crew alone & all discussions should be with your own training Dept's.

good management of these highly efficient systems is a much better alternative to the poorly flown often uncomfortable manual approach & correctly flown will keep your scan as health as ever

Firstly; no-one, sensible, is hammering this crew. We are discussing a general dilution of skills of all us across the industry due to various factors. This crew are not the only ones in the world to have found themselves in this predicament, and they will not be the last. We are discussing the root cause of why they found themselves in an uncomfortable position.

Your 2nd statement needs reply. "Good management…. of the automatics…." again that is exactly the point we are discussing. The lack of training in their full potential. Rigid SOP's teaches only a % of the options. I know only a tiny % of how to use my I-phone 4s. Once I know how it works to do the jobs I want I am happy until I reach a point where I need to do more; or I see someone else with magic fingers performing the most amazing feats. I then want to know more. Up until hen I was content. SOP's are similar. Enough to do the daily job in an ideal world; but is there a full understanding, and confidence, to use the system the way it was designed, in full?

You say "correctly flown approach" will keep your scan healthy. There i must take issue because of observation in the real world. Flown is not something using automatics: that is managed or monitored. Healthy scan when the automatics are doing the job, usually reliably, can be very scant and cause pilots often to be passengers in the cockpit. They sit and watch, but they don't think ahead and anticipate. They don't scan the raw data performance instruments. I've asked F/O's what the attitude is as they accelerate to retract the flaps: upto FL100 250kts: at FL250: at FL350 and what is the crz N1%. No idea. If you don't watch what the automatics do then how will you know what to do when in manual control? How do you know when it's all turning to worms and noticing that the automatics are not doing the correct thing? Let the a/c teach you how it want to fly and then emulate. A number of stall incidents over the past couple of centuries could have been avoided by looking at the attitude and asking what the hell was going on. AND taking over.
It takes a special attitude to be content to monitor automatics. The more you know how to fly manually the more you might be content to watch George. If you don't know the basics you don't look but you don't see.

[Arfur Dent]

Brilliant ponts Ratty! When I first converted from steam to glass decades ago, there was so much information in our lovely brand new Glass Cockpit that neither I or the FO knew where to look and what we were looking at/for. Clever Sim guy suggested something right at the beginning of the Simulator part of the course that helped enormously - we put the autopilot in and watched an approach from 2000' right down to an autoland. We noted attitudes, power settings, auto calls and all the other parts of a new machine (744 vs 747-200) including what the automatics did on the actual flare/landing/rollout etc. Don't just admire the automatics - scrutinise them and learn.
As you said Ratty, how many accidents could have been prevented by just setting a 'deck angle and a power setting' first and then - slowly - with one crew member just 'flying the plane' - try to troubleshoot.:ok:

[RAT 5]

Hi A.D. Your suggestion of an 'auto demo' is one I follow. I also get my guys to fly a raw data NPA using autopilot, but no F.D. Thus they do not get tunnel vision on something which will be a perfect cross all the time. It might not be in the correct place, though, as they are controlling HDG & V/S. Remove it and they quickly realise it wasn't helping them anyway. It takes their eyes out to the side of the PFD. And they enjoy the challenge.
I also demo stalls with/without FD's. That is also a shock, that the FD does not save them. Anything to get their heart and mind ahead of the a/c and keep them there.

[Arfur Dent]

Seen so many poor Go Arounds but less since we left the autopilot engaged and used VNAV for the vertical profile. (LNAV has been used for lateral guidance from way back). Far less confusion especially when all spd/ht constraints have been studiously checked beforehand. By definition, a Go Around is unexpected - great to see a good crew carry out a faultless procedure. Says a lot about them............

[RAT 5]

Seen so many poor Go Arounds but less since we left the autopilot engaged………

Therein lies a clue. On the B737 the autopilot, single channel, will disconnect when you press TOGA. The A/T will remain in the same state as when TOGA is pressed. Thus, many G/A's (should never be a surprise) are conducted in manual pitch & lateral control. If the A/T is not in use that can add a further complication; and if it is in use in can cause an added confusion. B757/767 is too long ago to remember, but I suspect an autopilot G/A was only from a triple A/P approach.

[BARKINGMAD]

2 pennyworth to move the discussion on a different track, NPI.

Having logged the surface wind, presumably looked at the HSI wind arrow and clocked the W/S reports, why such a high G/S downwind and on base, thereby setting up the scenario for a possible rushed approach?

The difficulty in establishing the LOC likely resulted from this, along with ATC vectors being a possible contributory factor. But then it's up to us GOFs never to shy from hinting to ATC that a different intc vector would be appropriate in the met conditions?

Then, when faced with an instruction to go-around from ATC, was/is it really necessary to go for a TOGA & likely high energy mode when already at 1500' agl? In addition to the rare surprise all-engined G/As, which should be part of the 6-monthly check, why not at least discuss in the sim briefing room other ways of performing a DISCONTINUED APPROACH, which don't rely on auto-flight modes but is still a safe and more passenger-friendly and tired crew-capable way of calling off an approach, especially if not IMC?

This capt PF was obviously distracted and more than likely knackered after the long duty starting early, we've all been and will be there too often, but once again I ask if the concept of Energy Management in all flight phases is a much neglected part of the training/testing environment?

Re the utilisation of sim time, I recall with disgust and frustration the many OPCs where by the time we got "airborne" for the duty predictable EFATO, more than 1 hour of sim time had been squandered on the classic 1st flight of the day cold start full cockpit setup, popped CBs, de-icing and LVO briefings involving normal checklist, supplementary checklist and the operators own Operational Procedures checklist plus engine start malfunctions, lo-vis taxying and the duty RTO. Aaaaaarrrrgh! ! ! ! !

There has to be a better way of using expensive and valuable sim time. I stress I'm not putting the blame on the TREs/TRIs, I'm joining the existing chorus of those on this thread who are vainly challenging the xAAs various to wake up and smell the coffee and join the rest in the auto-dependant 21st century!!! :ugh:

[RAT 5]

You need to change your name to "clear & loud common sense."

I too am tongue biting hair out-pulling frustrated at spending 1 hour in FFS TQ courses doing full cockpit set ups and briefings. The guys can't fly the a/c and
are eager to learn; meanwhile they sit on stand learning feckall because the already know how to make the mouth music of briefings and load an FMC from class-room time. AGH! Over the sessions of FFS 4 hours = 1 session is lost to this less important task.

[Smokie]

Funny you should bring up "Discontinued Approaches"
That is exactly what we had in the Sim last week. Was told to " Go Around" at 2000 feet during LVP's on the approach at HEL. Go Around Alt is quite low at 1500. So disengaged approach mode, pressed vertical speed zero ( press to level off) it dumps the flight plan though as TOGA not selected so flight plan not sequenced. No big deal, activate secondary, unless you have something else in the secondary, we had a copy of active. Not the sort of excersise we would normally do on an LPC though but definitely worth it :ok:

[Jwscud]

One big issue with this is that once you are in Approach mode, Boeing makes it pretty hard to get out again. Push TOGA, retune the ILS or disconnect and recycle the FDs. The only one you're conditioned to is pushing TOGA.

I learned this the hard way in MAD where they told us to level off after we'd captured the glide and been cleared for the approach. It's not difficult, but once again it requires training, awareness and thinking about it beforehand.

[BARKINGMAD]

"One big issue with this is that once you are in Approach mode, Boeing makes it pretty hard to get out again."

Jwscud, I can't speak for the 'bus, but agree with your comment re the Boing.

This implies that once on the glide, we're virtually "trapped" by the automatics.

If in doubt, then "clickety click" each of A/P and A/T and make the 'frame into a great big basic trainer, FLY THE AIRCRAFT, then brief PM to reassemble the autos into something relevant. But I suspect there are training and management types out there who would frown on this as an "escape manoeuvre"?

If as PFs we're incapable of that, then there are other careers out there more suitable.......................?

Rat5, you speak good sense in your postings, pity those who lead and legislate are not in contact with this discussion and loads of others in the various threads. :)

[dash6]

Or just press GA then another pitch mode.

[DooblerChina]

it's only difficult if one hasn't thought about it. 757 Go-around from above = go around switch followed immediately by v/s. it's very straight forward. In fact a go around in the 75 is very straight forward. This crew just cocked it up. I'm sorry but thats pretty much sums it up for me.

We have had pages of excuses ranging from poor ATC to poor bird management to poor training but non of them cut it.

Birds happen, go arounds happen and TCX's training I'm sure is very good. If the crew were unhappy flying manually then they should have practiced more. Hand flying is encouraged at most UK airlines when the conditions permit exactly for the reasons that the report highlights.

Let this be a lesson to all.. keep up those skills and do well what we are payed to do well in...

[Jwscud]

BARKINGMAD - it's not that we aren't capable, it's just not a manoeuvre discussed or prepared for. In our case, we disconnected and levelled off, followed by a bit of button pushing and confusion before FDs were recycled and we got George back into the game.

If training departments don't discuss these scenarios or throw them in, people will only learn when they find it on the line. An awareness that whatever is set in the MCP and whatever your position relative to that altitude, that hitting TOGA always gives you a climb command is also not always present. If you get trigger-happy with TOGA the moment someone says go-around you can find yourself in trouble. Our training department now teaches "take a deep breath" for unanticipated go arounds above minima.

[misd-agin]

Cycle both FD's, at the same time, OFF then ON. Reselect a mode desired. It takes a matter of seconds.

[dash6]

Misd. Why? See above. Same effect.

[BARKINGMAD]

"followed by a bit of button pushing and confusion before FDs were recycled and we got George back into the game."

Which is why I suggest if unsure as to how to escape from G/S engaged ILS mode via "a bit of button pushing" followed by a slight climb/descent to leveloff, then NO AUTOs followed by deliberate reconstruction and engagement might be more desirable.

The risk is that a 73NG locked into the ILS mode and 2 A/Ps engaged below 2000' RA when it is "instructed" by pressing TOGA, then the power comes on and the pitch starts towards 15 nose-up. Doing this well above DA risks the sort of undesired higher energy state which is what we may be trying to avoid.

So pressing TOGA followed by another pitch mode can introduce the sort of confusion and loss of SA which afflicted the TCX crew, unless this sort of DISCONTINUED APPROACH manoeuvre has been practised and/or briefed and understood beforehand.

[framer]

Cycle both FD's, at the same time, OFF then ON. Reselect a mode desired. It takes a matter of seconds.
Maybe that works on the 757, I've never flown it, but it won't work on the 737-800. You'll still be in approach mode but a few seconds will have passed. If you fly the NG misd-agin , then that is a great example of how the confusion can begin and why it is important to be able to simply fly the aircraft to where you want it ( which I'm sure you can....I'm not having a dig at you in any way).

[misd-agin]

@dash6 -


I'm not against using the TOGA switches if the situation calls for it. For low altitude G/A's it ** IS ** the correct procedure.


Is this case it should have been used but once the situation became less than ideal the basic option of cycling the FD's, establishing a known A/P mode(verified by FMA) and A/T or manual thrust configuration would have made this a minor event that the crew could have talked about afterwards.


Deselecting the FD's and reselecting them covers multiple situations after the A/P is in engaged in the approach mode. Especially if the approach clearance is cancelled or modified after LOC/GS capture.


Had to deselect and reselect the FD's sometime this summer. I forget the details but it takes approx. maybe 10 seconds to reestablish a desired, and known(just selected/verified mode), automation mode.

[misd-agin]

Framer - I agree about pointing the a/c in the direction you want. If automation isn't working, is erratic, or the operator has mode confusion knowing how to quickly establish a simple a/p mode is key. Cycling FD's accomplishes this.

I've been 737NG qualified. Cycling FD's worked on our 737NG's to exit approach capture mode.

[framer]

Is it the 757 where cycling the flight directors takes you out of Approach mode?
On every 737NG I have flown it wouldn't work. When the F/D's go off the a/p goes into CWS pitch and roll, and when you bring the F/D's back the FMA's come back in VOR/LOC and G/S, you are exactly where you started, in Approach mode.
Is the NG the only Boeing that does this? If the 757 doesn't behave like this then I guess it's irrelevant to the topic and I'll drop it.
Cheers

[Oakape]

As Jwscud said earlier, on the 737, including the NG, you need to disconnect the autopilot as well as cycle the flight directors to get out of approach mode. Of course, if the autopilot is not engaged, just cycling the flight directors will do it. Also, re-tuning the VHF nav receiver will also do it, as well as selecting TOGA.

If you turn the flight directors off with the autopilot engaged, the autopilot will stay in approach mode & the FMA indications will remain the same. The only thing that will happen is that the flight director bars will be removed from the PFDs.

[RAT 5]

God forbid to think about what we did before Flight Directors. Attitude & Power seems to work most of the time with or without Factum Dictatums

[misd-agin]

My apologies. I was talking about operations AFTER disconnecting the a/p.

Step 1 - fly the airplane.

If the airplane is not heading in the right direction and time or direction of flight is key and the automation isn't working as desired, or there's any automation confusion, the a/p is coming off. That's where my recycling the FD comments start.

[biggles61]

Easiest way to get out of approach mode in an NG is to deselect LLZ frequency on navs. A/P will then revert to CWS pitch and roll and then you can select whichever modes you like. Or even easier press TOGA and hand fly the aircraft.....

[Landflap]

C'mon Mods. What has all this to do with the thread ? Best for most of the development to shift over to Tech-log. On thread, I remain interested in why they went through the LOC in the first place and how has the company handled the incident.Not in a morbid fashion but consulting with other airlines on disciplinary and re-training methodolgy. Notice the BA Joburg incident. Aircraft totalled, airfield building demolished and the guys are back flying. Hope
upon hope that the TC guys were given a fair hearing and remedial action in the training dept taken in order to avoid a repeat.

[Deep and fast]

I can't believe the 73! In my aircraft if you want to go around, push the red button on the thrust levers, watch the flight director pitch up and apply thrust. Go pink screen lnav and its done.

[a1anx]

Automation doesn't replace basic skills.

[Lord Spandex Masher]

D and F, they're talking about alternative ways to GA in instances where you don't want TOGA.

Pressing the red tit still works, 'cept it's black.

[PEI_3721]

I haven’t seen that this study was referenced earlier, but sometimes GAs don’t go as imagined. Note the opportunity for distraction, workload, inadequacy of SOPs, etc. etc.

Aeroplane State Awareness during Go-Around. (http://www.bea.aero/etudes/asaga/asaga.study.pdf)

[Mr Optimistic]

Well as a pax this looks likes a tired crew caught out at the last moment then everything contaminated by growing concern as to what just happened.

[framer]

As a pax do you think the industry needs to ask;
Why were the crew tired and do we want to take steps to reduce the likelihood of crews being this tired?
Why were the crew "caught out"? Was it lack of training? Inappropriate training? Lack of experience? Inappropriate attitudes? Poor automation design? Lack of systems knowledge ? ( read checking and training)
Why was everything contaminated by growing concern as to what just happened.? Inadequate CRM? Degraded mental/ emotional state? If so why?
Or shall we just leave it be?

[IcePack]

Interesting discussion. Sometimes things happen & the aircraft runs away with you & quick thinking is required. Sometimes brain is too slow. I always found automatic ap engaged go arounds in the 75 were a dream manual ones you needed to be aware of early alt cap.
Airbus things are different I've had ap engaged go arounds try & stall the aircraft taking it into VLS especially on those without global speed protection. Had them try & over speed the flaps. Ie accelerating faster than the flaps can run. But manual go arounds are a little easier as you can vary the pitch.
But the BIG caveat in all cases click click FD off and fly the B'dy aeroplane works even if you are a little slow in doing so & may get a small level bust.
I have sympathy for this crew as sometimes aircraft do something you don't expect usually your fault but the human brain can only process things at a given rate & dumps stuff IT thinks it doesn't need. First to go is hearing for instance.
So as others have said. Their are those who have & those who will.
(Mind you some have the ability to blank out their past errors & deny they ever made a mistake)

[The Ancient Geek]

Rule number 1:
NEVER let the aircraft get ahead of you.

Part of every approach is to fully brief for a possible go around.
Clearly this was not done and the crew were caught with their pants down.

The moment the aircraft gets ahead of the pilot all bets are off.