TransAsia in the water?

[16024]

Quote:
Originally Posted by AAKEE
Bottom of the drag curve, lovest foot per minute descent.
On the high speed side of the drag curve, where a straight line from origo(at zero winds) meets the drag curve, you would find the speed for best glide i guess ?
No, you seem to be confusing the drag curve with the power curve.

Maximum range is at the bottom of the drag curve, but on the power curve it's where it meets the tangent from the origin.

But doesn't that only apply in cruising flight? When lift equals weight, then best L/D is at minimum drag, by definition. But it was my understanding that in a glide, the lift vector will be greater than weight, and will vary with speed such that best glide will be at a higher speed (more lift) than max range speed (minimum drag) or the even slower max endurance speed (minimum power).

I know it's a bit pedantic, and probably off topic, but I had it straight in my mind until now...

[lomapaseo]

Toruk Macto

Could a certain engine part fail and give indications that eng is still producing some power when in fact it's not ? Or eng surge give ind that eng may have failed but actually still operating ?

Simple answer = yes

That's why we need analysis of the CVR and DFDR beyond what this discussion board is working with.

[Lost in Saigon]

Thanks for the clarifications, guys.

Wasn't the call "engine flame out" simply reporting the fault indication that lit up on the flight deck, rather than a confirmation that any engine had in fact flamed out?

I don't think so. The Mayday call was at 10:53:34

On Feb 6th 2015 Taiwan's ASC reported that the investigation so far determined from flight data and cockpit voice recorders:

the aircraft received takeoff clearance at 10:51L, in the initial climb the aircraft was handed off to departure at 10:52:33L.

At 10:52:38L at about 1200 feet MSL, 37 seconds after becoming airborne, a master warning activated related to the failure of the right hand engine

At 10:52:43L the left hand engine (engine #1) was throttled back and at 10:53:00L the crew began to discuss engine #1 had stalled.

At 10:53:06L the right hand engine (engine #2) auto-feathered. (This is incorrect. #2 auto-feathered at 10:52:38) (Maybe they meant #1 auto-feathered at 10:53:06)

At 10:53:12L a first stall warning occured and ceased at 10:53:18L.

At 10:53:19L the crew discussed that engine #1 had already feathered, the fuel supply had already been cut to the engine and decided to attempt a restart of engine #1.

Two seconds later another stall warning activated. At 10:53:34L the crew radioed "Mayday! Mayday! Engine flame out!", multiple attempts to restart the engines followed to no avail.

At 10:54:34L a second master warning activated, 0.4 seconds later both recorders stopped recording.

Later the day Feb 6th 2015 the ASC also released an English version of the initial release detailing further that when the first master warning activated associated with the right hand engine the crew "called it out", then the left hand engine thrust lever was progressively retarded to flight idle.

At 10:53:24L the condition lever was set to fuel shut off position resulting in the shut down of the left hand engine. Following several call outs to restart the left hand engine the parameters suggest the left hand engine was restarted at 10:54:20L, however, at 10:54:34L another master warning sounded, the CVR recorded unidentified sounds and both recorders stopped.

[henra]

...
plenty of evidence to suggest they may not have been stalled. That they were close to the stall appears to be in no doubt.


I sincerely hope you are not a Pilot. If so, please let me know which Airline so I can avoid it.

Even if you are in a glide it is not a good idea to fly close to stall Speed, no matter what the circumstance. This only reduces your vital margins (against stall or loss of directional control) and Options (by significantly deteriorating L/D and thus glide distance).

Stall is at Cl max. Best L/D is at waaayyy lower Angle of attack than this. Hadn't they flown so slowly they might have been able to pass the Bridge without stalling and losing the left wing. This would have increased chances of survival even after the fatal mistake of shutting down the wrong engine (which - admittedly- isn't a first in aviation).
In so far People who insist on: Keep airspeed, don't rush things are absolutely right. This case here is about as good an example for this as it gets.

[error_401]

Too little information at this time.

There is a lot of important information missing from the plot as well.
Autofeather on the ATR used to be linked to the thrust selection knob whose position is not reported. Moving to climb would cancel uptrim and autofeather. Depending on what profile they flew this might have already been the case.

Did a few hours on type ATR 72-200's and it should be controllable with a non-feathering prop at any speed above Vmca. Be quick but you should have the "one" second to react and make sure you got it right. I can confirm the torque increase when going to feather making a bit of a yaw to the good side before telling you clearly which one has failed. Just keep your nose straight.

We'll have to see what the DVDR and CVR analysis together with the data that can be recovered from the ECU's and maintenance computer will show once examined.

IMHO the funny things in the data plot released are:

Why did they move the PL's so erratically?
Why the funny movement of the PL #1 in several steps to idle?
Why moving PLA #2 to MAX shortly before 02:53.15
The fuel flow on #1 increases shortly when #2 fails and nearly at the same time the PL #1 is reduced.
The PL #2 stays at TO and is then increased to MAX.
The rhythmic fluctuations in torque and oil pressure need an explanation.

What exactly is TQ1 and TQ2 versus Objective TQ1/2?

[Trackdiamond]

ENG FLAME OUT (QRH 2.10)

Memo items:

1) PL (affected)......FI

2) (pre-conditionally...) If NH drops below 30% (implies no immediate relight)
CL (affected side)....FTR then FSO.

Preconditions:
* if damage suspected
Fire handle affected side pull
Single Eng Operation procedure (2.04)....Apply

*if NO damage suspected
Eng Restart in flight procedure (2.08)....Apply
If unsuccessful
Single Eng Operation Procedure (2.04)....Apply


It would be interesting to time this procedure versus the time they had..added to the confusion that ensued that led to the throttling back and shutting down of Eng #1.

There is no QRH procedure I know of for uncommanded Feathering..only for prop Over speed and Lo Pitch in flight (whichs as I poointed earlier in this forum, is a memo item

PL affected .....Idle

CL affected ...FTR..FSO


If there were Abnormal Eng Parameters there is a QRH procedure that addreses that.

It involves trouble shooting with ATPCS OFF and with adequate flight situation..
PL affected ...FI
EEC affected side ...OFF
(If successful)
One EEC fault procedure ....(2.09)apply
(If unsuccessful)
-or if TQ=0% and NP<77%
PL affected side...FI
CL affected side....FTR...FSO
Single Eng Operation Procedure.... apply

Avoid sudden PL movements.

This all looks like a handful of SOP in the time and Altitude available.

The check Airman might have suggested the PF just flies the plane at VmLB0 and focus on flight path while the other 2 crew members purely run the checklist and ATC and Cabin communication.I don't know if they would have fared any better if the power producing engine was indeed shut down.

[Trackdiamond]

The. ECU (Engine control Unit) ceased since the advent of the 500 series and replaced by EEC..Electronic Engine Control...more automated in supervision and electronic engine control where the PLs were operated on scheduled gated notches..similar to A320 family and the PMS..Power Management selector in conjuction with EEC and ATPCS manages the engine power in its various flight phases and the CLs in Auto mode manages RPM.Fuel is metered automatically according to some engine control laws.So much automation could lead to pilots getting confused..as to what is it doing now?? Before control intervention..Where as conventional power controls..pilots react instinctively by adding or removing power more directly.

On this type of power Management the Pls are (for normal ops) in the notch and PMS regulates optimum power for the EEC computed ambient conditions.If more power is required for emergency contingencies the PL can be pushed futher up to the ramp..and if still in dire need for extra power..the PL can be advanced to "the wall" (no firewall as such in this type..).

To add complexity to the power management system there are the Multi Function Computers that supervise and authorise certain operation. The ATR is not your conventional steam gauge turboprop as those who have flown it will tell.

[TheInquisitor]

Even if you are in a glide it is not a good idea to fly close to stall Speed, no matter what the circumstance. This only reduces your vital margins (against stall or loss of directional control) and Options (by significantly deteriorating L/D and thus glide distance).

I don't think anybody here is claiming that flying close to the stall speed is a good idea - it's not the point I was trying to make, at least.

A number of posters are claiming that they were 'definitely' stalled - likely based on presumptuous analysis of video footage. My contention is that the data so far available suggests otherwise - at least for the majority of that descent. In the last seconds - almost certainly. But by then they were out of options and likely just doing what they could to avoid the worst of it (high buildings / roads / built-up area)

Loss of directional control in any ME aircraft has little to do with stall speed.

I sincerely hope you are not a Pilot. If so, please let me know which Airline so I can avoid it.

I'm guessing that you are not - at least, not multi TP.

Let's not forget, 15 people survived this - it could have been ALOT worse.

[flyingchanges]

If the ATPCS was still in TO, would moving the PL to idle initiate an autofeather?

[ACW342]

I have watched the videos of this terrible accident several times. I have nothing to add to the many technical discussions, nor do I have a publishable opinion.

There is, however, one thing I can inform you of and that is that the last few seconds of flight of the aircraft in this accident match exactly that of the last few seconds of flight of a Canberra BI 8 flying a practice asymmetric approach into RAF Wattisham in, I think, late 1969.

I was on duty in the Runway controllers caravan observing the approaching aircraft when, at about 2 1/2 miles the aircraft began to pitch up and the left wing began to drop, eventually going beyond the vertical. the aircraft then rolled to the left and after one and a bit turns impacted the ground, nose and left wing tip first. to my (then) young eyes the aircraft appeared to fold into itself and quietly exploded. Both crew were killed.

As far as I can remember the BoI concluded that the pilot had allowed the speed to deteriorate to the point that the aircraft entered the pre-stall buffet whereupon he moved both throttle levers to full. With the left engine at a low power setting to simulate failure, and the right engine at a much higher power level, the resultant asymmetric thrust caused the nose to pitch up and roll the aircraft, which stalled and spun into the ground

As stated earlier, what I saw as a 19 year old U/T airman (which has stayed with me all my flying life) and what I saw in the video of this accident were, apart from the end outcome, exactly the same. The river in Taiwan was more forgiving than the farmland in Suffolk.

The accident I witnessed was, if I remember correctly,the 23rd fatal PRACTICE asymmetric in the Canberra. I believe there were no fatalities in actual asymmetric landings.

[skyhighfallguy]

It has been said before, but back to basics may very well prevent total disaster in flying.

I looked at an image of the cockpit of the ATR72. The airspeed is a small sort of vertical tape common to modern displays.

We all remember when the airspeed indicator was a large gauge, in the first place on a left to right scan.

Airspeed, Pitch/Bank Attitude, Altimeter

The above tells you the health of everything in the plane. Airspeed high, climbing, nose up...all is well

Airspeed low, descending, nose down? Engine dead!

Take care with the yoke and then fool around with the other fancy knobs.

NOW before some of you remind me, there are failure modes of airspeed that might fool you, but if you have proper reading instruments, the truth is easy to see.

[Trackdiamond]

Might TransAsia ATR72 have experienced a similar snag on #2 engine?Was there aan EEC problem or propeller Module Valve issue?

AT72 experiences unwanted propeller autofeather during descent in hrl airspace. - NASA ASRS (http://www.37000feet.com/report/426719/AT72-experiences-unwanted-propeller-autofeather-during-descent-in-hrl-airspace)

[TheInquisitor]

ACW,

The many Canberra asymmetric accidents are well documented, and you have just spurred my thoughts a little.

If you look at the endgame part of the FDR, you can see the beta on #2 reduce as soon as the #2 PL is retarded - it started to unfeather, with a still-lit engine. I wonder if this is what caused the final departure from controlled flight, and came as a complete surprise to the PF?

[hikoushi]

IIRC in the Dash-8 we practiced uncommanded feather as a lead-in to engine out procedures in the sim (had happened to someone at one point). First thing you see is extremely high torque values as the prop is trying to slow down. Procudure was power lever flight idle, condition lever start/feather then fuel off if the feather worked out okay. Been a bunch of years, so could be off in my memory (FCOM is up in the attic somewhere).

[hikoushi]

IIRC in the Dash-8 we practiced uncommanded feather as a lead-in to engine out procedures in the sim (had happened to someone at one point). First thing you see is extremely high torque values as the prop is trying to slow down. Procudure was power lever flight idle, condition lever start/feather then fuel off if the feather worked out okay. Been a bunch of years could be off in my memory (FCOM usual in the attic somewhere).

[henra]

I don't think anybody here is claiming that flying close to the stall speed is a good idea - it's not the point I was trying to make, at least.

OK, then I probably got your Point wrong.


A number of posters are claiming that they were 'definitely' stalled - likely based on presumptuous analysis of video footage. My contention is that the data so far available suggests otherwise - at least for the majority of that descent. In the last seconds - almost certainly. But by then they were out of options and likely just doing what they could to avoid the worst of it (high buildings / roads / built-up area).
The stall is not a Black/White Thing. Separations over the wing Profile start to grow much before Cl max. This progesses up to the point where the lift starts to decrease despite increasing AoA. That is also the reason why L/D takes a significant hit way before Cl max.
I agree that they were probably not in a stall as of being beyond Alpha(Cl max). Still they were surely operating at an AoA with significant separations and rather bad L/D.


Loss of directional control in any ME aircraft has little to do with stall speed.
Not directly with stall speed but definitely with Vmca. Being slow doesn't help with this. At all.
That's my Point.
Had they succeeded in getting the second engine back online and to full power in the attitude they were in in the last 5 - 10s would only have led to them crashing in a spin in opposite direction.


I'm guessing that you are not - at least, not multi TP.
Indeed I'm not. Engineering Background.


Let's not forget, 15 people survived this - it could have been ALOT worse.That is because they crashed into water which prevented a fire plus they lost control only in the last 2-3s.
Hadn't they lost control surely more could have survived.
This is not about crucifixation of the poor guys in the front Office who surely didn't want to die that day.
It is about stressing that even with a total engine failure keeping of airspeed and control is essential for such a heavy lump of aluminum in order to make it as survivable as possible. Getting below best glide Speed will only reduce your Options and make it even less forgiving.

[Iron Duck]

If you look at the endgame part of the FDR, you can see the beta on #2 reduce as soon as the #2 PL is retarded - it started to unfeather, with a still-lit engine.

Call me thick (or not a pilot, which here amounts to the same thing), but I don't understand this. How can it be that the prop will start to unfeather when the power lever is retarded? How can the prop be feathered on a lit engine with the power lever full up? Is what you've just described not confusing, anomalous or unfathomable behaviour?

[olasek]

Let's not forget, 15 people survived this - it could have been ALOT worse
Sure, somebody else could have screwed up even more. There is always a room to make things even worse. Somebody else could have flown into a side of an office building...

[TheInquisitor]

Henra,

Hadn't they lost control surely more could have survived

I'm not so sure about that. The more I look at it, the more I'm convinced that the last few seconds of that flight were pure serendipity. They may well have been looking at a nice big fat field the other side of the river as their preferred forced landing location, when all of a sudden, the #2 fires back into life by unfeathering and flips them over. There's little to suggest (to me, at least) from their flight path that they were aiming for a river ditching as their solution - but impacting the opposite bank would perhaps have been far more likely had it not happened.

Since you were much more measured in that last post, please allow me to retract the implied ad hominem from my last response... I have to be honest, I'm a little prickly (and disappointed) at the massed hordes seemingly intent on apportioning crew blame before all facts are known...

[wilyflier]

At the height shown in videos it was too low/ too late to dive to regajn best glide speed ;all they could do was maintain existing speed in the mush with nothing left for a flare
I would also comment that freewheeling unpowered declutched prop creates very high drag, which increases if you try to speed up; been there, done that. glide slope decreasing to 2:1

[henra]

I would aim for the most open space I could see vaguely in front of me, and fly at whatever margin I could achieve without the stall warner going off.... easing off on the back pressure a little every time I heard it.


This is exactly the technique I had some objections with.
If you want to get anywhere, don't fly close to stall. Gliding faster (at best L/D) will get you further and leave you more Options where to put it down.

There is absolutely no benefit I could conceive in gliding down close to stall speed when having lost all engine power.
Ask the sail plane guys. They are flying with engine failure all the time...
And they would never, ever try to slow close to stall speed when trying to glide as far as possible.

[Iron Duck]

If you want to get anywhere, don't fly close to stall. Gliding faster (at best L/D) will get you further and leave you more Options where zo put it down.

It's quite possible that they didn't want those options. It seems that there was only one optimal touchdown point; beyond the field lay more buildings. What's the use in gliding at best L/D to end up overflying the landing field and smacking into a building? They had what appears to be the only possible field in front of them (and a short field at that), with power lines in the way. Over, or under? If over, how to lose the excess height & energy?

It seems to me that looking through their windshield the crew might have thought it quite possible that their flight path would have landed them where they wanted to be, after passing under the power lines, and perhaps with a final pull on the stick (having read Think Like A Bird I assume an ATR's flaps don't travel as quickly as a Beaver's).

Then #2 decided to intervene.

[porterhouse]

It's quite possible that they didn't want those options.
Then they were really bad, bad flyers. Perhaps as bad as some of the armchair pilots on this forum.
River was everywhere along their path and that's a perfect landing opportunity. And the bridges were sparse enough. Had they executed a controlled landing on the river everyone could have walked away.

Looking for a place to land was the last thing on their minds.
You got this one right.

[noalign]

Actually, it appears that they were both feathered after about 02:53:31 ...

I await a correlation of the CVR with the FDR. Hopefully someone will post a link when it appears in the wild.

[Trackdiamond]

Clearly the #2 engine was what started this whole fendengo. That was the culprit engin...whether by analogous indications, unwanted autofeather, or just plane flameout.So that engine should have been shut down.reducing ITT is the easiest indication of an engine flameout.

If in their muddle they shut down engine one and left the shutting down of eng 2 incomplete..that was what gave them all that unwanted drag and lost speed control in the process whilst panicking where to terminate the flight.The river and its easuaries gave them plenty of ditching options and that rever bed being shallow would have been advantageous in terms of evacuation.

Perhaps having shut the wrong engine(had they realised it) better to have moved CL2 to FSO.Then dry motor eng #1. Before starting it to purge any fuel and insure against a hung start.With engine one started and eng 2 shut down..they woukld have been able to climb away to their single engine ceiling whilst sorting the problem with 2 or simply return and land in controllable condition.

I also wonder if PL2 was retarded out of the TO notch..because that hard roll over would have been caused by sudden excess power from eng2 if it it unfeathered itself and the PL was in the notch...especially if climb sequence wasn't yet performed and hence TO torque kicked in with the PMS selector on TO.
It was the drag mess they got themselves in that betrayed helpless state..

[xmh53wrench]

A few questions if you folks dont mind...
1. Are the torque spikes recorded due to the feathered props still slowly spinning in the air?
2. Am I seeing the correct indication of a gradual yaw to the right from 1100 feet to 1350 feet, and does that prove #2 feathered as normal flight path is 114-116 degrees through 2250 feet?
3. Could this be masked by an automatic rudder input after the feather of #2?
4. Does anybody else think they were headed for Sun Yat-sen Freeway till they got near it and realized it was unsuitable for landing as it is boardered on either side by elevated freeway and its too narrow to accommodate the wingspan?
(I believe that may have been where the real panic would set in)


Thanks in advance. I am also curious if there is more on the CVR than what has been released so far.

[Trackdiamond]

To your 3rd point.

Could this be masked by an automatic rudder input after the feather of #2?
The yaw damper(auto rudder as you put it) might have been at it.It is normal practce to have it on even with the AP disengaged till short finals to countermand strong crosswinds.In this case I don't know if it remained on if the AP was on at that stage or if disconnected by any assymetric yaw due to Eng 1 shut down.


We are taught early not to attempt forced landing on a busy freeway..especially with a wide wing span and electric poles and other obstacles.The rivers away from bridges offered a more sensible landing site option.I think they were planning that r they wouldn't have been that close to it.

[Volume]

This entire catastrophe could have been caused by a decision in aviation in general to follow manufacturer's aged logic and not implement changes based on operating experience. Not entirely true, in fact even worse...
If operating experience shows 1% too high fuel burn or .5% too low dispatch reliability, something is changed.
If operating feedback from pilots identifies weak points of the aircraft or built in traps, maybe the pilot training is improved, but nobody would improve the aircraft until some serious incident results in according official safety recommendations.
Same applies for feedback from maintenance.
Aviation has always relied on in-service feedback, but this element is quickly fading away as nobody listens to pilots or mechanics any more, and management only worries about economic aspects.

[Jet Jockey A4]

Doesn't anyone find this strange...

The authorities were really quick to release some DFDR information (day after the crash) which at the moment is incomplete and lead us to think the pilots shut down the wrong engine, yet no English version/transcript of the CVR is available.

Before making a judgement, I would like to see more and explained DFDR information and certainly an English version from the CVR of what was said in the cockpit.

[Trackdiamond]

Yes we need an explained CVR full transcript corelating to the DFDR

It is also a wonder that even the world media have shut up on this news.What has ATR themselves got to account for in all this?

[FullWings]

From what we have been told, that they shut down the wrong engine, got to the edge of stalling five times then spun it in, it doesn’t look like there was much spare capacity left to navigate around obstacles and/or pick somewhere for a forced landing. At the speeds they were flying at, there will have been very little manoeuvre margin, so any determined attempt at turning would have ended in a rapid departure, like the one in the final few seconds. The crash site was likely selected by the aircraft rather than the pilots, although the CVR should provide some enlightenment.

The crew makeup is another classic: two captains and a F/O. Loads of potential CRM, authority gradient and simple unfamiliarity issues. In my (Western) airline, we don’t allow this kind of crew composition unless the capt. in the RHS is a trainer and checked/current for the RHS. It’s also only rostered for training duties.

A few questions to those who are qualified on the 72-600:

I understand it has auto feather in TO mode, as well as uptrim for power and rudder auto-trim for any asymmetry. Is the auto-trim always engaged? Also, would you consider use of the autopilot in a non-normal situation like this or is that non-SOP?

[Old Gilb]

If operating experience shows 1% too high fuel burn or .5% too low dispatch reliability, something is changed.
If operating feedback from pilots identifies weak points of the aircraft or built in traps, maybe the pilot training is improved, but nobody would improve the aircraft until some serious incident results in according official safety recommendations.
Same applies for feedback from maintenance.
Aviation has always relied on in-service feedback, but this element is quickly fading away as nobody listens to pilots or mechanics any more, and management only worries about economic aspects.

True words nowadays - I 100% agree! Thank you, Volume!

[HarryMann]

...I doubt there is much difference in distance with this configuration
between minsink and max glide speed.
it was all about getting some power back into the equation.

Wing drops on high aspect ratio aircraft can be as much about
drag as loss of lift. that is.. the wing is dragged back slowing it
even more.

[Bigpants]

This weeks Flight has an article on TransAsia (page 7) which points out that since 1995 this airline has suffered 7 significant safety incidents including the loss of 3 other ATRs and 1 Airbus A321.

The most severe prior incident was the crash of an ATR 72-500 in Magong on 23 July 2014 which resulted in 48 deaths.

By all means discuss the technical aspects of this incident but the real question for me is why was the Airline permitted to keep flying when it has such a poor safety record?

[bud leon]

Kaboy:

Read my posts....I am not blaming the crew, I am apportioning blame on a culture that is prevalent in Asia! It starts with the regulator and works itself down to the operators. Incompetence has developed through lack of proficiency and oversight.

I work in Asia.......culture has a lot to answer for.

Air Safety...... look at this operators history!!

Asia: 4.4 billion people in 49 countries. Generalisation much? I also work in Asia, and it's my opinion that anyone who talks about "Asian culture" talks about human culture but hasn't worked out that not looking caucasian does not automatically equate to incompetence, lack of proficiency and foresight. Tell me how it is that Asia is the fastest growing economic region in the world. Is it through culturally embedded incompetence?

Maybe Air Asia has a safety problem. I don't specifically know. I certainly would want more than raw incident data to draw a conclusion. The United States has the largest prison population in the world, and the second-highest per-capita incarceration rate. Going by your mode of assessment, Americans are a bunch of criminals.

I post this because I think all the predominantly western criticism of Asian aviation safety on this forum, often based on a bunch of premature conclusions, needs to be rebutted.

[Phileas Fogg]

I live in the Philippines, here many of the regional airports are little more than landing strips, taking my local airport for example, something like a 1,400m runway, no navigational aids, no runway or airfield lighting, no fuel, lots of high ground around, and the local airline, weather permitting, put ATR72's in and out up to 7 days a week and, fingers crossed, they do it safely.

And isn't Cathay Pacific an Asian airline? ... How many of you lot would like to fly the approach in to the old Kai Tak airport each and every time you were returning to home base?

[macdo]

Possible answer to your post is that Eastern WORK culture is similer in some ways to Europe was is the Industrial Revolution. The attitude is to make money quick and hang the consequences.Health & Safety naaa, Slave Labour pay yeeeess! Industrial Relations and Unionisation naaaa! Safety Culture was that then? Command Gradient, Alpine Black Run!
The East will inevitably change and modernise, but in the meantime we can expect more industrial accidents, which sadly includes aviation. Just my opinion, of course.

This might not sit very comfortably with the many professional aviators in the East, but the accident stats published speak volumes.

[DouglasFlyer]

@bud leon

Thanks for your post - if there were a "like-button" I would definitely push it. Operating for decades into Asia I agree with you!

[funfly]

It's culture not intelligence that seems to be the problem.

[Trackdiamond]

Now that this subject has been opened for discussion can we begin by defining what this "Asian culture" being referred to in here means? There is still a high proportion of non Asian western and other pilots serving the carriers in Near East and Far eastern Asian countries so let us be absolutely sure what we are projecting in bashing this Asian Culture.Let us be specific so we can arhue it out and be more learned shall we?

[lomapaseo]

Yes we need an explained CVR full transcript corelating to the DFDR

It is also a wonder that even the world media have shut up on this news.What has ATR themselves got to account for in all this?

Yes a full analysis of the CVR and DFDR is needed. That takes time so don't expect it for a while.

Analysis of this detail ids done behind the scenes with expertise and joint party cooperation. It typically doesn't get published until it is understood and agreed by the majority.

The world media has already satisfied the majority of their readers with news releases and have moved on to other news of "todays" interest elsewhere.

ATR has no need to jump ahead of the investigation by announcing opinions until/unless they need to publish a recommendation specifically concerning their product.

[Trackdiamond]

I agree with all you have quoted. I understand Accident investigation enough to know the lead times involved and dissemination of "filtered" information..but that doesn't stop the public demanding it.

Little was revealed to the public concerning the possible crew error..after they were hailed as heroes..it was left at that.Could it be the Taiwanese authorities have muscled their objection against any further media reporting?

Am sure if it was a systemic problem on the type under investigation EADS/ATR would have dissemninated an AD or SB by by now. It is upto ATR726 operating crew who are members of this forum to tell whatever they know that could benefit this forum with our curious analyses.It would seem this story has already lost momentum until something new develops.
Perhaps it is time to move on.

[Hunter58]

Airbus would do what?

ATR is an independent company from Airbus, even if the latter by name is a 50% shareholder and a subcontractor for the assembly line. The other 50% are with Italy...

If anyone publishes anything concerning ATR it will be ATR itself.

[FullOppositeRudder]

The has been a lot of discussion about stick and rudder skills - or perceived lack thereof.

This series currently showing in Australia on SBS TV has been very interesting viewed against this background of this discussion. OK, there's a bit journalistic drama added, but I would sit behind these pilots anywhere ....

Here is a youtube URL for the first in the series:

https://www.youtube.com/watch?v=xBu-2EP_eMU

It's an English production; maybe most PPruNers have seen it before. (It sometimes takes while for these things to reach the southern colonies).

[broadreach]

FullOppositeRudder, thanks for the link.

Perhaps mistakenly, I'm trying to compare PNG flying with bush piloting in other parts of the world. The guys interviewed and filmed in your linked clip seem to be mostly Europeans looking to build hours and an entry to regionals and then majors in Europe. Pretty much the same in the Americas although for some reason I get the impression that North American bush pilots like what they do and stick with it.

I wonder, are there no Chinese, Indians, other Asians in Susi's PNG ops and those of their contemporaries?

[oblivia]

Asia: 4.4 billion people in 49 countries. Generalisation much? I also work in Asia, and it's my opinion that anyone who talks about "Asian culture" talks about human culture but hasn't worked out that not looking caucasian does not automatically equate to incompetence, lack of proficiency and foresight.

I've lived and worked in Asia for 15 years (nothing to do with aviation) and I think I understand what is meant by such comments—deference to authority, rote learning, superstition.

I agree that much of this is not unique to Asia and is typically a question of economic and social development. But that doesn’t make it any less real.

Which countries in Asia are not top-down, hierarchical societies? Which have a strong rule of law? Which have vibrant democracies that give voice to ordinary people? Which have a free press that encourages accountability for those at the top? Which have a tradition of independent academic enquiry? Which have a welfare system that means people aren’t terrified of losing their jobs? Which are free from corruption?

The answer is that no country in Asia has all of these things, and most have none of them at all. It’s not about race or culture—it’s about the basic institutions of advanced democracies.

It’s not my place to say how much any of this matters when it comes to CRM or aviation safety, but my lay view would be that I notice less of this deferential conservatism in free but poor India, and more of it in rich but restrictive Japan/Korea. (Plenty in SE Asia and China too.)

Even so... I suspect that such things only have an effect at the margins, which is not to say that they are unimportant, but a far bigger challenge is how Asia will find the 500k+ new pilots (plus another 500k+ mechanics) that Boeing predicts the region will need during the next two decades. It seems unlikely that these new pilots will be getting extra hours in aerobatic planes (or even extra hours in a sim)...

[ekw]

Oblivia - very well put. Of course personality plays a role as well. There are plenty of narcissistic captains of all nationalities who would crucify you for correcting them if you turned out to be wrong.

[Icarus2001]

Bashing "Asian culture" does seem to be a default position for some. However...

I post this because I think all the predominantly western criticism of Asian aviation safety on this forum, often based on a bunch of premature conclusions, needs to be rebutted.

I think it fair to say that it is based on statistics...

http://www.fearofflyinganxiety.com/wp-content/uploads/2013/08/safest-airlines.jpg

Go to page 20 of this report...
http://www.icao.int/safety/Documents/ICAO_2013-Safety-Report_FINAL.pdf

Lies, damn lies and statistics?

[marchino61]

Go to page 20 of this report...
http://www.icao.int/safety/Documents...port_FINAL.pdf

That chart shows only the percentage of accidents that occurred in each region. Without knowing how much air traffic there was in each region I'm unable to compare how many crashes there were per flight or per million miles....or any other sensible definition of safety.

[cris95123]

Asian culture is.120 hrs By month...... on ATR It Looks like 120 legs a month.....Tired crew never do good job...EVEN in asia......thailand DCA have been downgraded to level B ...next Taiwan
My personal records on ATR
India ........125 hrs
Philippines .105hrs
Indonesia ...113 hrs (28 days)
Thailand .....129 hrs (28 days)
my colleagues records
Laos ........+120hrs ( 13 days duty w/o day off)
Indonesia ...140 hrs
Taiwan........120 hrs
In Asia ..they believe FDTL is minimum duty.... ;))

[FlightlessParrot]

Now that this subject has been opened for discussion can we begin by defining what this "Asian culture" being referred to in here means? There is still a high proportion of non Asian western and other pilots serving the carriers in Near East and Far eastern Asian countries so let us be absolutely sure what we are projecting in bashing this Asian Culture.Let us be specific so we can arhue it out and be more learned shall we?

Two points made in a recent article in the New Zealand Morning Herald:

1. The FO was born in Hong Kong, and spent 15 years in New Zealand, including secondary school and initial flying training, thus, highly formative years. Excessive deference due to cultural factors is less likely, then, I think (especially as Hong Kong, on casual observation, does not seem exactly hide-bound).

2. There was some discussion as to why someone with so many hours was FO, and the phrase "command failure" was bandied around. The article claims he was, in fact, a captain, called in to fill an FO's shift.

Alas, the article refers to him as "hero pilot," but we don't really know yet, do we?

http://http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11397934

[Shaggy Sheep Driver]

There was some discussion as to why someone with so many hours was FO, and the phrase "command failure" was bandied around. The article claims he was, in fact, a captain, called in to fill an FO's shift.

If you read back to the relevant posts you'll see why it's postulated that his being a captain might have been part of the CRM problem (if there was a CRM problem - it looks that way right now, but we don't have CVR yet).

[Iron Duck]

I've lived and worked in Asia for 15 years (nothing to do with aviation) and I think I understand what is meant by such comments—deference to authority, rote learning, superstition.

Any objective look at different cultures will reveal their different propensities to deferentiality. Japan remains quite deferential; it's a culture of which I have long direct experience. On the other hand, deferentiality can crop up anywhere. The cockpit of the KLM 747 at Tenerife turned out to have been a highly deferential society.

The CVR will eventually reveal whether undue deferentiality was a significant factor here.

[FrequentSLF]

That chart shows only the percentage of accidents that occurred in each region. Without knowing how much air traffic there was in each region I'm unable to compare how many crashes there were per flight or per million miles....or any other sensible definition of safety.

pag 10 have a table showing the accident ratio per million departures

[Fareastdriver]

I think it fair to say that it is based on statistics...

Fear of Flying - Learn how to overcome flying phobia (http://www.fearofflyinganxiety.com/w...t-airlines.jpg)


Apart from Xiamen Airlines, a minor player in China, none of the Chinese (China Airlines is Taiwan) airlines feature. Chinese airlines are the major people movers in Asia.

[Lonewolf_50]

Just a thought for the culture club here:
How many years or decades did it take the "Western" airlines and cultures (and for that matter military cultures) to address cockpit gradient and develop other CRM concepts and tools that are now industry standards?

How much effort went into that, and still goes into that? It didn't just happen.

One of the challenges inherent in this progress is a bit of a paradox: the Captain bears ultimate accountability for the conduct of his flight. This won't change any time soon, and so the balancing act has to be dealt with as an ongoing challenge for any captain/aircraft commander. It takes effort and development of some of those "people skills" that don't fit nicely into boxes and checklists.

As we used to say about a lot of thing: "If this stuff was easy, anybody could do it."

Back to the accident at hand: if there were confusing indications of what was wrong with the #2 engine, wherein the interpretation of what the engine and its instrumentation were telling the crew, what were they? If it was enough to induce the captain to command the good engine to shut down, the community who fly this model of aircraft would likely benefit from understanding that anomaly.
Possible CRM issue: when you both can't agree on what's wrong with the engine ...
When available, a CVR transcript might be very educational.

[HDRW]

I've been looking at the FDR traces that have been released, and would like to share my analysis.
My credentials: I'm an amateur at this, but I have been debugging computer systems for over 40 years, so I'm used to looking at what evidence there is, and trying to work out what happened.

So: "Correct me if I'm wrong" applies to all of the below! When I say "the system" I mean some part of the automation - I don't know enough to say which particular box is involved, and it doesn't really matter at this point. All times are approximate, as it's a bit tricky to interpolate between the marked times.

It looks like everything was OK until 52:30. Then (at about the same time):
Objective TQ1 rose to 100%
No.1 Bleed Valve was closed
Prop.2 started to feather

I believe this is "Autofeather and Uptrim" by the system, because it believed No.2 engine had a problem.

Engine 2 Flame Out Warning was given
Fuel Flow 2 started to reduce, followed by No.2's ITT and RPMs (NL, NH, NP) and torque.

This seems to be the system bringing No.2 back to Idle, but without moving the Power Lever (can it do that on this aircraft?)

I'm going to call the small amount of time over which the above happened: "Point 1".

52:40 As a result of the above, No.2 spooled down, and by now it was at idle, feathered. (Its torque trace starts a strange triangle-wave, with about a 4-second period, spiking from zero up to about 150%.)

Power Lever 1 is retarded a bit, I'm assuming by the crew. CVR would be useful at this point to find out who/why.
They are still climbing, albeit slowly, until:
53:04 PL1 is retarded a lot further, then further still, then PL2 is firewalled, then PL1 pulled back further still, with consequent reduction of TQ1 to practically zero. Prop.1 is still in normal pitch and NP1 is about 80%, so for the next five seconds or so it must be windmilling. I'm calling this "Point 2".

53:20 Prop.1 starts to feather and Fuel Shutoff 1 is closed, shutting down that engine, (and with its torque trace taking on the same triangular wave pattern as No.2, and then its oil pressure trace doing the same thing).

53:28 they have both props feathered, No.1 shut down, No.2 idling but with its PL still firewalled, and they're at about 1200', descending.

Without the CVR we can only imagine what happens in the flight deck for the next three-quarters of a minute, but then:
54:14 Fuel Shutoff 1 is reopened, PL1 advanced slightly, so this is a relight attempt. They are at about 700'. "Point 3"

54:19 No.1 is spooling up, but Prop.1 is still feathered and not really turning.

54:27 Power Lever 2 is retarded most of the way, the Flame Out 2 warning stops, and Prop.2 starts to unfeather, so the system seems to think No.2 is OK now, and starts to spool it up, but it never contributes any thrust - unfeather never completes and the RPMs and torque barely get off the stops before the end of the trace, so I don't see the "sudden thrust from No.2 raised the right wing" happening, as some have said.

As I see it these are the questions:

1. What caused the system to "think" there was a No.2 flameout at Point 1? Before that the engine indications should still have looked normal to the crew, but it seems they had no chance to override the spool-down that resulted, and perhaps no reason to think they needed to.
2. Why was PL1 retarded 10 seconds after Point 1? It wasn't to shut down the engine as it was only a 10degree change.
3. At Point 2 they seem to have ignored the normal readings of No.1 and the "Idle" readings of No.2, and shut down No.1 Is this a "confirmation" problem because they were expecting No.1 to be a problem before they set off? Also, would the windmilling No.1 "confirm" they were shutting down the bad engine?
4. Why did retarding PL2 clear the erroneous Flame Out condition (not just cancelling the warning, but also bringing up the fuel flow and unfeathering)?
5. If they had retarded PL2 at Point 3 instead of trying to restart No.1, would they have got out of the situation in time?
6. (Unimportant) What's with the three triangle-wave traces?

Finally, why are the FDR traces all engine related, except the Main Gear, VHF1 (what is this?) and height readings? Where is the airspeed, vertical speed, control positions, etc?

Cheers,
Howard

[Lost in Saigon]

.........................

Back to the accident at hand: if there were confusing indications of what was wrong with the #2 engine, wherein the interpretation of what the engine and its instrumentation were telling the crew, what were they? If it was enough to induce the captain to command the good engine to shut down, the community who fly this model of aircraft would likely benefit from understanding that anomaly.
Possible CRM issue: when you both can't agree on what's wrong with the engine ...
When available, a CVR transcript might be very educational.

I would be very surprised to find out there is some kind of and "anomaly" which contributed to them shutting down the wrong engine.

It shouldn't be the Captain ordering which engine to shut down. It is the Flying Pilot(FP) who instructs the the Non-Flying Pilot(NFP) to do the engine shutdown drill (memory items) or engine shutdown checklist.

Shutting down an engine is not a one step process. First the NFP placed his hand on the power lever and asks the FP to confirm it is the correct one. Then the NFP will slowly bring the power lever to idle. After those first two steps you should know with 100% certainty that you have the correct engine.

If all looks normal to both pilots(three in this case) then the NFP places his hand on the Condition Lever and again asks the FP to confirm he has the correct Condition Lever. THEN you bring the Condition Lever to the Cut Off or Shut Off position.

I have done hundreds of shutdowns in the Simulator and occasionally someone will start by placing their hand on the wrong power lever. Usually the flying pilot will catch it. In a very few cases they will miss identify the power lever and end up pulling back the power on the working engine. There is instant feedback that you have the wrong engine and a simple push forward on the lever fixes everything.

It is very difficult to imagine how this experienced 3 man crew accidentally shut down the WRONG engine if they followed the correct engine shutdown procedure.

Yes, it will be VERY interesting to read the CVR transcripts.

[Royale]

1. What caused the system to "think" there was a No.2 flameout at Point 1? Before that the engine indications should still have looked normal to the crew, but it seems they had no chance to override the spool-down that resulted, and perhaps no reason to think they needed to.
2. Why was PL1 retarded 10 seconds after Point 1? It wasn't to shut down the engine as it was only a 10degree change.
3. At Point 2 they seem to have ignored the normal readings of No.1 and the "Idle" readings of No.2, and shut down No.1 Is this a "confirmation" problem because they were expecting No.1 to be a problem before they set off? Also, would the windmilling No.1 "confirm" they were shutting down the bad engine?
4. Why did retarding PL2 clear the erroneous Flame Out condition (not just cancelling the warning, but also bringing up the fuel flow and unfeathering)?
5. If they had retarded PL2 at Point 3 instead of trying to restart No.1, would they have got out of the situation in time?
6. (Unimportant) What's with the three triangle-wave traces?

Very interesting analysis HDRW.

1. Could the ATPCS system have erroneously activated and feathered prop #2? It looks like a distinct possibility.

2. We will have to wait for the CVR for that one.

3. We will have to wait for the CVR for that one.

4. I believe that as part of the start sequence for eng #1 the crew selected the PWR MGT switch to MCT, thereby cancelling the autofeather signal from the ATPCS system, this i think caused eng #2 to begin to revert to normal.

5. I don't think so, as I believe this to be an ATPCS issue.

6. I have seen DFDR spikes before and they seem to appear when the recorded value is 0, some sort of "noise" on the recording, I am certain that they are not relevant to the accident.

[Royale]

If all looks normal to both pilots(three in this case) then the NFP places his hand on the Condition Lever and again asks the FP to confirm he has the correct Condition Lever. THEN you bring the Condition Lever to the Cut Off or Shut Off position.

On the ATR you even have an intermediate position before fuel shut off, called feather, and you really don't want to go past that point unless you are 100% certain. I doesn't take that long to unfeather the propeller again.

[skyhighfallguy]

royale

can you tell me how the right engine/prop is placed into "HOTEL MODE" for ground use as a pseudo apu?

[pattern_is_full]

Finally, why are the FDR traces all engine related, except the Main Gear, VHF1 (what is this?) and height readings? Where is the airspeed, vertical speed, control positions, etc?

The FDR tracings cover multiple pages (unless graphed at too small a scale to be readable/useful). The parameters you mention are on a different page - not yet released.

[Royale]

can you tell me how the right engine/prop is placed into "HOTEL MODE" for ground use as a pseudo apu?

It is done via a guarded swith on the overhead panel, ac needs to be on ground,gust lock engaged and prop #2 feathered.

If that had been a part of this accident there would also have been a prop brake unlock warning.

The prop bake is not capable of stopping an unfeathered propeller, it will destroy the propbrake itself by heat, and possibly cause a eng fire warning too.

[skyhighfallguy]

thank you Royale. The Hotel mode concept is a strange one to this pilot. Could any aspect of hotel mode be figuring in the right engine / prop combination not producing thrust?

[Royale]

I really doubt that the propbrake played any part in this.

I know of an incident where for some strange reason the crew attempted a takeoff with the propbrake engaged, it resulted in the propbrake mechanism disintegrating due to excessive heat, and a fire warning due to that heat. But no loss of thrust.

[Lost in Saigon]

On the ATR you even have an intermediate position before fuel shut off, called feather, and you really don't want to go past that point unless you are 100% certain. I doesn't take that long to unfeather the propeller again.

Is it Standard Operating procedure to pause at the FTR position or is it just an airmanship thing?


http://i2.photobucket.com/albums/y17/msowsun/photo%20stuff/photo16/ATR-72-600-Engine-Controls1.jpg~original

http://i2.photobucket.com/albums/y17/msowsun/photo%20stuff/photo16/ATRPn06_400.jpg~original

[lomapaseo]

When trying to interpret the DFDR traces give a thought that the sampling rate of its data trace could be much coarser than the detection rate of the computer systems that automatically control its functions.

the way to get beyond this is to trial model some engine performance graphs and then see which ones best match the actual DFDR traces.

[Royale]

Is it Standard Operating procedure to pause at the FTR position or is it just an airmanship thing?

Its procedure in a sort of roundabout way. All irreversible actions have to be confirmed by both pilots, moving from FTR to FUEL SO is irreversible in the short term.

The procedure itself state:
CL affected side.............................................. FTR THEN FUEL SO.

[skyhighfallguy]

royale

I notice the 100% ovrd position and below it auto

would auto be used for arming auto feather on takeoff?
if you autofeather, do you go to 100% ovrd to disengage?

or you can just brief all of us on the different positions.

[strangestranger]

IF the prop was autofeathered as part of the ATPCS sequence, the only way to unfeather is by selecting power management selector to MCT. Any ATR pilot would know this.

[ChicoG]

https://www.youtube.com/watch?v=cXTGzO-mCJo

[Lost in Saigon]

IF the prop was autofeathered as part of the ATPCS sequence, the only way to unfeather is by selecting power management selector to MCT. Any ATR pilot would know this.



http://i2.photobucket.com/albums/y17/msowsun/photo%20stuff/photo16/0213257.jpg

[Trackdiamond]

The DFDR analysis posted by HDRW queried why PL1 was retarded some 10 degrees..this was likely to countermand the uptrim on Eng 1 which the crew reckoned it to be unnecessary due to figuring that Eng 2 flameout was probably a false alarm.After that particular action am not sure what kind of comunication was taking place but it vertainly was confusing and the CVR is the only thing that can disclose the truth.I suspect very much it was either an ATPCS, EEC, or Propeller PVM (prop valve module) issue.The fact that the power quadrant is a constant postion lever(gated) and power is regulated automaticvally could be some weird electronic issues at play.Also the PMS is split(two rotary knobs as one..required for certificationp.perhaps there was a disconnect between them that might have caused weird Power Mismanagement?This would have happened at acceleration altitude..anywhere from 400ft to 1000ft but on average 800ft as per company policy when switching it from TO to CLB as part of the climb sequence flow by NFP.

On ATR 500 series there was no QRh procedure for ATPCS failure! If on takeoff..increae PL manually to the wall.If in flight..it was unwritten..and one would switch it off..but no CCAS warning specific to ATPCS.If it wasn't working at dispatch it was MEL GO with a weight penalt of 3600kg..because of performance degradation due to its unavailability.

QRH procedure for Abnorma Eng Parameters in flight:
If intermittent fluctuations or unrealistic steady indication
ATPCS........OFF
*when adequate flight situation
PL affected side FI
EEC affected side...OFF
*(if successful)
One EEC fault procedure....Apply
*(if unsuccessful)
Or-if TQ=0% and NP<77%
PL affected side.....FI
CL affected side.....FSO
Single Eng operation procedure...Apply
*if "---" indication on Torque digital counter...Avoid sudden PL movements.

Hotel mode only a ground ops function.I have had a prop brake unlock but on the grounds..and had to shut down the engine and have maintenance check it as is the SOP.
Prop brake coming on in flight..QRH says continue normal ops...just monitor eng 2 parameters (prop brake on Eng 2 only).After landing...CL2...FSO.

By the way ...on ATR...the PF(handling pilot) is the one whose hands are on the PLs and PM(non handling and monitoring pilot) is the one who confirms and PF moves it to idle.On the other hand the PM has his hands on the CL and PF confirms and the PM moves the CL to FTR and FSO.It is the ATR SOP...PF handles the flying controls and power controls and the PM handles the critical switches wth PF confirmation.The CL os an engine start and prop feathering/unfeathering and rpm control switch...on jets it equstes to engine stat levers..which the PM handles...at PF conformation.

[Jet Jockey A4]

Our S.O.P.s and the manufacturer of the aircrafts we fly (not ATRs) the PF only flies the aircraft and guards the good thrust lever and shut off switch and upon his confirmation/command the PNF brings back the failed engine's thrust lever, turns off the engine shut off switch, generator etc.

[Trackdiamond]

I won't argue with that JJ.am just saying that was ATR SOP we used.I found it awkward at first but like any SOP..you adapt and make it your homeplace...regardless of what else you have flown before.

[Lonewolf_50]

I would be very surprised to find out there is some kind of and "anomaly" which contributed to them shutting down the wrong engine. My guess had to do with the nature of the malfunction and the display of symptoms, but you may be right that it was something well within the norm of the systems as known/trained.
Shutting down an engine is not a one step process.
Agreed. I am intimately familiar with the process, but thanks anyway for the excellent coverage you presented. :ok: I too have done many in sims, taught many in sims, and done it for real a half a dozen times on engines that weren't playing nicely with others.
It is very difficult to imagine how this experienced 3 man crew accidentally shut down the WRONG engine if they followed the correct engine shutdown procedure. Aye.

[no-hoper]

Uptrim without a reason and no TQ increase.
Autofeather of a nice working engine.

I call it malfunction.

[jommasipi]

The analog Tq meter and the atpcs system get their Tq information from Tq sensors in the engines. If the sensor gives incorrect information this may at least in theory activate the ATPCS and thus the autofeathering of a fully functioning engine. In the FDR picture that I have looked at (http://pbs.twimg.com/media/B9JarHTIAAAgAy3.jpg:large) it seems that the torque of the autofeathered engine was norman until the feathering started. So it seems that the torque has not dropped and thus activated the ATPCS cycle. But there are two differend methods to measure the Tq (I don't remember the other one precicely but it is calculted by the engine control system) and the one that is visible in the FDR tape may not be the same Tq information that is used by the ATPCS.
In ATR MEL it is a normal procedure to turn off the ATPCS system for takeoff and use 100% Tq if the analog Tq meter is not giving correct information. This is because there is a risk that the malfunction is due to broken Tq sensor and it might activate the ATPCS in a fully functioning engine.
If you look at the ITT of the engine #2 it stays at about 400C after the feathering. The engine #1 drops quite quickly to around 150C after it is shut down. To me it seems that the engine #2 was just running on idle and feathered all the time. But power lever of engine #2 was at full power all the time. I have never tried what happenes when you feather an engine with full power in ATR but there might be a logic in the EEC that turns the engine power to idle or near to idle despite that the power lever is in full power.
The situation was most likely confusing. At least in our company we have never simulated inadvertent autofeather in simulator. I don't know what happens in such situtaion.

[Lost in Saigon]

Uptrim without a reason and no TQ increase.
Autofeather of a nice working engine.

I call it malfunction.


The #1 uptrim was due to the auto-feather on #2. There WAS an increase in Torque on #1 from 90% to 100%.

#2 was not working properly, that is why it auto-feathered. It is all in the data:

ITT dropped
NP dropped
Fuel Flow dropped
Torque dropped
NL dropped
NH dropped

http://i2.photobucket.com/albums/y17/msowsun/photo%20stuff/photo16/B9JarHTIAAAgAy3.jpg

[noalign]

So how does it Uptrim, Autofeather and close the live bleed before a loss of torque. Is loss of torque still the ATPCS trigger in the -600?

[no-hoper]

It. is all in the data.Indeed.Just read it..

Nothing wrong with No2.

Uptrim No1 for no reason.

Bleed off No1 correct,but TQ NOT increasing! Objective TQ is a calculation only.

2,15 Second after incomplete uptrim of No1 autofeather on the good engine No2.

[Trackdiamond]

Firstly.does anyone have a record of the time on ATR72-600 this combined crew had.Had they flown any other ATR series before?Have they flown any other turboprop before before? How much multi crew experience did they have before or were they predominantly military single pilot operation cultivation? This might lead to explain how they behaved if at all in appropriate.

I reckon non standard (non QRH referable) malfunctions, such as this MIGHT have been, at such a low altitude on a critical departure phase wuld likely lead to instincts taking over as there would be litle time to diagnose, formulate and decide and execute appropriately.I posted earlier an unwanted auto feather on an ATR72 on decent.It would be interesting to discover on which engine that took place and what the status of ATPCS, EEC and other related indications and mechanisms such as the Propeller Valve Module were commanding and indicating.The constant PL auto regulated power Management is quite unique to ATR as a turboprop and I wonder what anomalies were discovered during flight testing prior to certification. It might be that ATR the company knows something about this but is keeping tight lipped for legitimate reasons? The truth can only be collborated through CVR analysis...and the aircraft's techlog review..I suspect Transasia Engineers also might have something to contribute to this mystery.

[I-NNAV]

In my opinion the first event is the engine 2 who went idle by himself without a change of the PL, this generates the ATPCS intervention whith UPTrim and Autofeather after 2.15 sec.
Uptrim worked correctly but someone reduce the PLA to keep 90%...

[tartare]

Shades of Kegworth.
I assume someone's checked everything was wired up correctly?

[chuks]

I guess we will need the full report to understand who did what when, and in response to what oral commands. It's very difficult to understand what happened from the little we know.

At a guess, having two captains instead of the usual crew, a captain and an FO, may have led to some non-standard CRM after whatever triggered this accident. This is something that only an analysis of the CVR information can tell about, I think.

It seems from what we have read so far that the crew must have first either lost power on the right engine for some unknown reason, or else have been presented with a false indication of loss of power on the right engine. It seems that they then shut down either the (good) left engine or perhaps both engines, in response to whatever happened first.

Whatever happened to cause that, the crew seems to have found themselves with no power, at low altitude and low speed, in a place where there were not many places to make a reasonably safe off-airport landing.

Those videos seem to show an aircraft that is stalled and out of control, since it's first sinking, and then dropping its nose and left wing as it passes out of sight over the bridge. Too, the images of the wreckage in the river show it as inverted, which must mean t a fairly high rate of roll in the last few seconds of flight to end up that way.

[FlightSpanner]

It. is all in the data.Indeed.Just read it..

Nothing wrong with
No2.

Uptrim No1 for no reason.

Bleed off No1 correct,but TQ NOT
increasing! Objective TQ is a calculation only.

2,15 Second after
incomplete uptrim of No1 autofeather on the good engine No2.


It's all in the data, except for why #2 Engine detected Flame Out, from the data it does indeed look like there was nothing wrong with #2, however the EEC thought there was a Flameout.

Everything, airframe wise, worked as it should, Flameout detected so #2 engine reduced to idle without any PLA movement and autofeathered, #1 Engine Objective TQ increased to 100% and the engine responded, the uptrim of #1 was due to #2 reducing.

#1 engine followed exactly what was commanded, the crew reduced #1 PLA and the engine followed, why they did this is the mystery, the data shows no evidence of an engine stall or surge.

During the decrease of #1 engine PLA they also increased the #2 PLA, which at this point did nothing as the engine was at idle, my thought is they either had not noticed the #2 engine producing no power or had firewalled the power lever in an attempt to get some thrust back.

Someone also mentioned the spikes on the TQ data, I have seen this before on other aircraft and believe it's due to the signal being zero on that channel, if you notice the Oil px it does exactly the same when the #1 engine is shut down.

I find it hard to find a reason why they would shut down #1 engine if they knew there was an issue with the #2, even if the #1 was stalling, surging, making noises or anything else, so close to an airport, over urban terrain.

The only exception would be fire from #1, however the gradual reduction in PLA does not show standard engine fire procedures.

They either didn't know #2 was the trouble or if they did then they moved all the wrong engine levers.

[eZathras]

"... Taiwan's regulator revealed 10 of TransAsia's 49 ATR pilots have failed oral proficiency tests on handling an aircraft during engine failure"


See halfway down TransAsia Offers £307,000 To Crash Families (http://news.sky.com/story/1425373/transasia-offers-307000-to-crash-families)

[nerd317]

A bit more detail provided here...

Taiwan orders all airlines review safety after bad test results | Reuters (http://www.reuters.com/article/2015/02/11/taiwan-airplane-regulator-idINKBN0LF0MB20150211)

Taiwan's aviation regulator said 10 of TransAsia's 49 ATR pilots had failed oral proficiency tests on handling the aircraft during engine failure. A further 19 pilots did not take the test, due to sickness or because they were not in Taiwan, the Civil Aviation Authority (CAA) said. The 29 pilots who failed or did not take the test have been suspended, the CAA said.
[snip]

"Some of us have stayed up all night to prepare for the tests. The result will affect our career developments significantly," said the pilot, declining to be identified due to the sensitivity of the issue.

[HDRW]

FlightSpanner:

It's all in the data, except for why #2 Engine detected Flame Out, from the data it does indeed look like there was nothing wrong with #2, however the EEC thought there was a Flameout.
Indeed, and although this faulty "thought" caused the string of events to start, I wonder if they would have done any better if there was a real Flameout? I would expect a real flameout to be shown by a *really* sudden, low ITT reading, as it would be being sprayed by unlit fuel/air mixture, which would cool it down very fast (unless the flameout was due to fuel starvation, obviously, in which case it would just be cold air, but still much cooler than burning gasses).
Can anyone who's seen one comment on what a real flameout looks like on the gauges?
...
During the decrease of #1 engine PLA they also increased the #2 PLA, which at this point did nothing as the engine was at idle, my thought is they either had not noticed the #2 engine producing no power or had firewalled the power lever in an attempt to get some thrust back.
To me it suggests they thought that No.1 had failed, and they did a manual "uptrim" of what they thought was the good engine, without checking the instruments to confirm. What indication is there that the propeller is feathered, as it was when this firewalling of PLA2 took place?

Someone also mentioned the spikes on the TQ data, I have seen this before on other aircraft and believe it's due to the signal being zero on that channel, if you notice the Oil px it does exactly the same when the #1 engine is shut down.
That was me! So the system shows that sawtooth pattern to indicate: "This sensor is working, but is reading zero"? Sounds like a good idea, just surprised nobody has mentioned that - maybe a little-known characteristic?

[Johno8]

"Some of us have stayed up all night to prepare for the tests. The result will affect our career developments significantly," said the pilot, declining to be identified due to the sensitivity of the issue."

What?? What does that say about their proficiencies if they stayed up all night?? If they were flying and were faced with this kind of emergency I would hope they would know what to do, and not study all night to address the problem! I don't think the aircraft would be aloft long enough in an emergency for them to "study". :eek:

[funfly]

no more room for pilots on modern airplanes.

What rubbish.

At any given moment there are over 5,000 aircraft in the air, 24 hours a day and 7 days a week.

Because of the complexity most of these will be controlled by computers which can take decisions quicker than any human and store masses of information.

Once in a while, maybe once every month or so, i.e. once every million flights, the aircraft presents problems that are outside of the ability of the computer.

In these situations that aircraft will crash unless a 'human' takes over.

In 90% of the cases the pilot, due to training and experience, will rectify the situation and resolve the problem, often with little loss of life or aircraft.

Occasionally the pilot is not up to the situation either because the situation is beyond him/her or due to lack of personal ability. This results in tragedy.

The human pilot is always the last chance when everything else goes wrong. The answer lies in better pilot training and company procedures not removing the human totally.

[FlightSpanner]

HDRW

That was me! So the system shows that sawtooth pattern to indicate: "This
sensor is working, but is reading zero"? Sounds like a good idea, just surprised
nobody has mentioned that - maybe a little-known characteristic?


Unfortunately I cannot answer if this is by design or not, I've seen this when testing installations, once valid data was received the plot was normal, again I am no FDR analysis expert, just what I have seen during installation testing.

EnchevEG - can you backup claims that the FDR plot is fake? Must admit it did for a nano second cross my mind too, mainly because it was released so quick and also (as many others have said) it just messes with my head to think they shut the wrong motor down, all the indications/warnings were there for a #2 engine problem.

In the cockpit were six eyes, all able to see #2 Engine Flameout CAS and #2 engine TQ, ITT, NP & Fuel flow indicators.

It beggars belief!!

[funfly]

The cockpit voice recording is going to answer a lot of questions. Isn't it about time it was released?

[OntimeexceptACARS]

As a mere SLF would it not be the case that the issue isn't incompetent pilots, its incompetent training?

[Loose rivets]

. . . and the fuel booster pump question I've asked before.

Leaving them off has caused similar symptoms on earlier marks. At least twice with one company.


So, automatic on the 600 or still a vital something 6 eyes could miss?

No one?

[Carjockey]

Closing the stable door after the horse has bolted?!

Ten TransAsia pilots fail tests on how to handle plane if engine fails - Asia - World - The Independent (http://www.independent.co.uk/news/world/asia/ten-tranasia-pilots-fail-tests-on-how-to-handle-plane-if-engine-fails-10038039.html)

Can anyone please explain the airline management rationale for testing all it's pilots on type after the event? :ugh:

[ThreeThreeMike]

The discussion about whether the #2 flameout warning and automatic systems intervention was legitimate is quite beside the point. That sort of failure may occur, although highly unlikely.


More significantly, after the #2 autofeather the aircraft continued to climb quite nicely. For a few moments, that is.


It appears that proper cockpit procedures would have made this a non-event.

[chuks]

A Cockpit Voice Recorder is really there to aid in crash investigation. If the authorities want to, then I suppose they could release the CVR recording or its transcript to the general public ahead of the full report, which usually takes at least a year to prepare, but that might not be a good idea.

For one thing, in this case I suppose the crew were speaking Tawainese, so that most of us would need a translation to understand what was said. Too, we would usually need to combine the translated CVR transcript with the FDR data to see both what was said, but also what was done.

For instance, hypothetically, perhaps the CVR shows the PF commanding "Shut down Engine Number Two," but then the FDR shows the left engine, the wrong one, being shut down by the PNF. In a situation such as that one you would need more than just the CVR to understand what happened.

[TonyDavis]

Yes it is incompetent training.

Training in these areas, especially EFATO has been dumbed down over the years. The main blame can be laid at the door of the regulators by not ensuring technical knowledge competence after the scrapping of Performance A exams. This is a complex subject not understood by a great number of pilots. Whilst I was training new entry pilots I was amazed by the lack of knowledge. The previous poster was suprised that the pilots that were tested stayed up all night revising. Well I am sorry to shater your world, but the majority of aircrew do study for exams and sim checks.

There has been a rising number of accidents caused by lack of knowledge and this will continue to rise.

[Lost in Saigon]

Yes it is incompetent training.


I agree. Incompetent training and/or incompetent recurrent training and checking.

It would only take a day or two to examine the FDR and CVR to have a good understanding of what happened here.

The fact that the Taiwan's Civil Aeronautics Administration has ordered the pilots to undergo proficiency tests tells me they probably know exactly what happened and why.

[chuks]

No real need for a crash investigation, eh? A day or two looking at the CVR and the FDR and "Bob's your uncle."

Calm down, guys. Let's wait for the official report before we make up our minds about the cause of the accident, particularly since most accidents are taken to be the result of multiple causes. You know, that "accident chain" we are trained to think about as professional aviators.

[AAKEE]

@Lost in Saigon:

(as reference to post #580)

For me, using a ruler for exact reference, it seems like #1 uptrim came first. TQ1, Objective TQ1, FF1, ITT1 increases first and without torque on #2 falling at all.
If i did understand it right, uptrim and autofeather triggers by tourqe on "failing engine" falling below 18%. This do not seem to be the case, TQ2 even increases a little bit and it looks as it did it about when feathering started.

ATPCS faulty ?

[Lost in Saigon]

I agree, upon close examination the exact timeline data does look suspicious. But, even if the ATPCS was initially faulty, all the readings were showing a failed engine well before the good engine was shut down.

[deefer dog]

I don't think you can rely that much on the published FDR timeline when you see that the gear is indicated as being raised fractionally before lift off.

[rnzoli]

You are reading it wrong. That's not the gear up or down indication. It's the sensor in the gear, showing that the weight of the aircraft transitioned to the wings.

If you think about it, that's really important at least fractionally BEFORE climbing away, right? :)

[no-hoper]

@ Lost in Saigon:Not a single reading is showing a failed engine.

[Lost in Saigon]

@ Lost in Saigon:Not a single reading is showing a failed engine.

We are talking about #2 right?

Yes it was running, but it was at idle power and feathered. This happened without pilot input so it must be some kind of a failure.

[no-hoper]

No2 did a complete autofeather.Normal readings before AF and after.
The only signal to start the AF is torque below 18%.


ATCPS received a wrong signal.

[jack11111]

Does the DFDR readout of engine paramaters and other data, as presented in this thread earlier, occur in this order on a single page?


Perhaps through copy and paste, the data has lost precise timing and relationship.


Also, the use of VHF1 radio occurs at the beginning of these events. Coincidence?

[fireflybob]

The fact that the Taiwan's Civil Aeronautics Administration has ordered the pilots to undergo proficiency tests tells me they probably know exactly what happened and why.
And apparently 20% of them failed even the oral test.

Without knowing the exact nature of the oral test I don't think we can be too sure what this proves.

I would be more interested to see a pilot's performance in the simulator and/or the aircraft.

Don't get me wrong I'm not saying pilot's shouldn't be able to field relevant oral questions but there is a difference between "espoused theory" (what you say you would do in a given situation) and "theory in use" (what you actually do).

Whilst you would expect all pilots to know items such as Memory/Recall items etc this reaction seems like a "trapping" exercise rather than remedial/refresher training. Sort of shutting the stable door after the horse has bolted.

[HenryD]

Just read page 1 to 31 - lots of great deductions. I thought i'd summarize what I've read (from an aero engineer perspective)


1. FDR trace matches ATCPS system activating to retard eng #2 to idle + feather, eng#1 bleed off etc.

2. the FDR doesn't seem to indicate any prior reason for the ATCPS to activate (specifically no oil pressure drop or TQ drop).

3. The #2 engine maintains healthy operating parameters (al biet at idle) throughout, and shows a quick acceleration immediately prior to impact (ITT, NH, NP, FF all going up) - nothing to suggest engine has actually failed - at least not completely.

4. There have be previous incidents of erroneous ATR72 ATCPS activation.


initial cause faulty ATCPS?


5. There seems to be conflicting CVR transcripts so we can't really trust any - but at least one translation clearly states the pilots correctly identify eng#2 fail early in the piece.

6. FDR shows PL#1 retarded in stages and shutoff

7. FDR shows PL#2 set to 100% (whoever is moving the levers is moving the wrong ones - that much is clear!)

8. CVR then seems to suggest confusion in cockpit as to why eng#1 is feathered and shut-off - supporting the idea the pilots DID correctly identified end#2 as the failed engine.

9. Crew then attempt restart of #1 (~20s before impact) (again, they think the #1 is the good engine). Eng#1 responds to start but it's too late.

10. PM was used to sitting in the left seat as PF. He was called in to fill in and sat in right seat as PM.


All crew responses make sense IF you swap the levers. i.e. PL#1 with PL#2 and CL#1 with CL#2. Did PM mix up #1 and #2 levers from an unfamiliar seat despite crew otherwise correctly identifying #2 engine/ATCPS failure? (of course it would have been better if PM did nothing at all to either lever until everything calmed down abit)


the hole in this theory is why didn't PF/PM notice unexpected response to PL reduction and correct it? (there is 45s from initial PL reduction until FSO) - my only suggestion here is distraction by stall warning which occurs ~20s after PL reduction and subsequent information overload)


11. In the final moments ATCPS is deactivated (probably since pilots initiate restart procedure for #1 eng, moving PWR management to MCT, which deactivates ATCPS). the #2 eng unfeathers and begins accelerating once again suggesting the engine is actually in not too bad shape - i.e. ATCPS failure, not engine failure. In any case it's too late.


p.s. I suggest speed management and wing drop in the final moments is a bit of a red hearing. The only real chance these guys had in this hostile environment was restore power and fly away, although it maybe fair to argue the initial speed decay leading to stall (warning) was a unnecessary distraction.

[nnc0]

Also, the use of VHF1 radio occurs at the beginning of these events. Coincidence?

Auttomated ACARS event?

[skyhighfallguy]

not that I know anything about trans asia, but typically, acars is not using VHF number one.

Perhaps , when coordinated with cvr, we will find a radio call from the plane.

I read somewhere that a CVR transcript was to be released today, anything out there?

[jack11111]

My thought regarding VHF1 radio use is noise, perhaps RF spike or DC bus spike, being sensed by ATPCS triggering auto feather event. All it takes is a faulty ground or noise filter to be weak. Then its a matter of bad timing.

[thump]

I don't see the confusion. Were they not just radio calls (e.g. mayday)?

[PuraVidaTransport]

CNN is reporting that of the 49 TransAsia pilots the TCAA have tested, 10 of those have failed the oral exam and will need retraining before they are allowed back into the cockpit. The 39 who did pass will also have to undergo a simulator test session. There are also 19 other pilots who have yet to undergo the tests.

Not sure what it says about the airline when over 20% of your pilots (with an average of 6,900 hours) can't pass an oral exam but it sure can't be good.

TransAsia pilots grounded after failing flight test after crash - CNN.com (http://edition.cnn.com/2015/02/11/asia/transasia-crash-pilot-tests/index.html)

[noalign]

Lurking in the back corner of the room is the fact that on every check ride they took they secured which engine? and why? as dictated by how many different countries authorities?

[Derfred]

It would be pretty easy to design an oral exam to yield a high failure rate if that was the objective of the exercise.

I remember a checkie asking me one time how many wheel nuts were on the main gear.

[arizona]

How comes that the Taiwan CAA seems to be aware of the pilots proficiency first AFTER the accident?

[Greenlights]

For flying in asia, im not surprised at all in this kind of area. Those people do not have any questionning until things happen for real.:ugh: and ground staff is worse.

[JammedStab]

It would be pretty easy to design an oral exam to yield a high failure rate if that was the objective of the exercise.

I remember a checkie asking me one time how many wheel nuts were on the main gear.

Exactly...."what, you don't know the diameter of the prop", "you don't know the climb gradient at max weight on a standard day with one engine inoperative", "you are not aware of the prop blade angle at a certain station when feathered"....obviously you are not qualified to fly the aircraft.

[deefer dog]

Critical engine training by rote - very good point!

And what about the "alleged" pilot training in a sim with no operating rudder pedals? Has this been verified as being fact?

[Sikpilot]

It would be pretty easy to design an oral exam to yield a high failure rate if that was the objective of the exercise.

I remember a checkie asking me one time how many wheel nuts were on the main gear.


I got asked a ridiculous question like that once. Without missing a beat I answered "All of them or I will ground the aircraft". He smirked a little and went to the next question.

[ZFT]

And what about the "alleged" pilot training in a sim with no operating rudder pedals? Has this been verified as being fact?

I'm advised that this 'report', like many posts on this thread was not quite correct. Apparently the fault on the Singapore sim was there but for a few days only whilst spares were sourced and the sim was withdrawn from service.

So whilst not verified as untrue, now seems highly unlikely.

[nnc0]

Can somebody explain or offer some conjecture on why they initially reduced the PLA on #1 by only 10 degrees and then waited? Is that per the drill on a t-prop, improvised on the spot to investigate/verify?

[Smudger]

I'm a 61 year-old 757 captain with absolutely no intimate knowledge of the ATR.. I have had a few glasses of red wine as I post this so please excuse me.. I have always been aware of the fact that the most likely things that will kill you as you try to make your way in aviation are propellers or altimetry.. this is unfortunately borne out as true depressingly often.. I flew left seat in the C130 in the RAF and in the Fokker F27 as my first type after I left the air force so I know what it is like to operate propeller driven aeroplanes... all I'm saying is please let's cut these poor guys some slack until we know the truth.. if they messed it up then so be it but let's not crucify them prematurely... a lot of the posters here have been intelligent in their analyses but let's please just wait for the official reports before we pass judgement.. I'm not saying that people are being unfair on here merely that we need to wait until the truth be known.. and hopefully lessons will be learned... in this business we never stop learning do we ...

[OzSync]

Well said Smudger but I'm afraid you have no chance of that here.

Humble, competent, professional aviators would never be so quick to judge their peers with such a lack of information and when we do have the information, we tend to take the lessons learnt onboard.

Many people that post here are just not like this. Many are not professionals.

[Bergerie1]

Smudger and OzSync,

You are both so right. I flew for many years as a line pilot, training captain and flight manager. Much of our time was spent pouring over other people's accidents to see what we could learn and then to adapt our procedures and training routines as appropriate.

I note that many posters on Prune have considerable expertise, not only as pilots but also as trainers, accident investigators, engineers and software designers, etc. Their analyses are helpful and constructive. They illuminate many little known aspects of our profession and are to be welcomed.

But there are others who either know little about real aviation or who jump to inappropriate conclusions and comments. Please don't! Please take care not to besmirch the reputations of fellow aviators who are in no position to defend themselves. And please spare a thought for their relatives, friends and colleagues before rushing to judgement.

[MichaelJP59]

I for one do not mind the ongoing speculation, though with every accident thread I think we reach the point where there is nothing more useful that can be gleaned or concluded from the patchy leaked information. I think we've passed that point here, but no doubt the discussion will continue.

For those concerned about premature criticism and judgement on the pilots actions, we should bear in mind that none of this judgement carries any weight whatsoever.

[clunckdriver]

Yes, there is much uninformed drivel on most web sites, however the root problem is getting little coverage in this PC age we live in. Let me explain, on my retirement from the heavy metal I was contacted by a recruiter to teach at a major Asian airline, so I went to look at their operation and in doing so sat through a few of their sim rides, what I saw was totally unbeliveable! The rides totally ignored basic flying skills and were so scripted that if the exercise called for say a cargo fire, the candidate had to be informed just which cargo hold the fire was to be in, if one switched the fire location it was considered "unfair" and if they scewed it up {which they did} it was struck from the file, and so it went on during every sim session I witnesed, I could go on for hours recounting what I saw in their training department, but there is no way these crews were up to standard, if one then factors in the cultural problems,{the captain is a God} there will be many more of these sad events. When I declined the position their answer was to offer more money, no critical observations were tolerated. Yes, I know Im non -PC, but Im too old to change!

[Smudger]

Clunk..

Not non-PC at all.. just telling it how it is... we know this goes on but it's still frightening reading

[Shaggy Sheep Driver]

Maybe if enough people like clunck who are qualified to observe that these airlines are not up to standard continue to offer solid examples like this, it will be picked up by the media. If pax vote with their feet and avoid these carriers as a result, things might improve.

'Ang on. A pig just flew past the window. But at least it knows how!

[pontifex]

During my 60 years as a professional aviator, both military and civil (QFI and FI) and, finally designing and running an MCC course I have trained a great number of nationalities from all parts of the world. I fully concur with all that Smudge and Clunk have posted. I won't bore you with any examples, but I agree it is frightening.

[Bergerie1]

Pontifex, Smudge and Clunck,
I don't doubt that what you have seen is correct. I have seen something similar. In which case it it the management and regulators who are to blame.

[fox niner]

Maybe pontifex, clunkdriver, smudge and others should PM each other so that they can team up to contact the authorities / the press. Would be another contribution to flight safety.

[Hotel Tango]

Maybe if enough people like clunck who are qualified to observe that these airlines are not up to standard continue to offer solid examples like this, it will be picked up by the media. If pax vote with their feet and avoid these carriers as a result, things might improve.

I have done just that, i.e. avoided these carriers for a long long time already. Unfortunately the majority of passengers are just simply price driven and not aware of the dangers associated with many of these Asian carriers.

[Smudger]

Fox..

Thank you for your confidence but I'm afraid if we did as you suggest it would fall on deaf ears anyway.. all the press are interested in is selling papers so if it hasn't crashed yet it's not newsworthy.. as for the authorities well where do we start...it's a huge problem and to be honest I don't think there will be a solution anytime soon... just choose who you fly with very carefully.

[MPN11]

Hotel Tango ... some SLF read PPRuNe and know exactly which airlines to avoid. This SLF does not, and will not, set foot on any minor Asian carrier [and even some big ones].

The message is actually clearly out there in the media, if people have the wit to read and interpret, instead of going "awwww, that was awful".

We value our remaining years.

[skyhighfallguy]

foxniner

the press is aware. but tell me, what method would you use to prove it, to fully protect your company and you from libel suits?

you can't just say: some guy on pprune says this and that.

and don't think you can get into trans asia's training program with cameras, recorders etc.

you can watch, glean and prepare for the next one.

[Slippery_Pete]

If this is simply as it appears... Autofeather #2 (perhaps ATPCS error, doesn't matter) followed by crew pulling torque off and eventually shutting down the operating engine, then the lesson to be learnt is very simple.

Why the #### are these things being shutdown close to the ground? At one turboprop operator I worked for, they were adamant the shutdown with a V1 failure was to be done at acceleration - sometimes as low as 500'. It was mind bogglingly stupid, but it still happens in turboprop sims the world over.

The only reason a shutdown should be actioned so low is for engine failure followed by failure to auto feather (a desperate situation indeed, yet one which had NEVER occurred since type certificate issue, worldwide, on the airframe I used to fly).

The case of a fire may also warrant an immediate shutdown, but should be with fire handle and fire handle alone.

Manipulating power levers and fuel shutoffs just after takeoff when one propeller has auto feathered and the aircraft is still completely climb-able and controllable is just nuts.

That's why these damn things have auto feather in the first place.

If it's climbing, sit on your hands and keep it flying. Anything and everything else can wait.

I hope desperately this was not a case of shutting down the only engine which was developing power.

[BlueVolta]

So well said.
If it flies, just let it fly until a decent acceleration altitude that gives good ground clearance.
The engines are certified in RTO for 10 minutes, so at least 1000 ft allows for some margin if something goes wrong.
At 400 ft AGL, there is very little margin to correct an error in a turboprop as drag and yawing movement will make the aircraft hard to control.

[edmundronald]

Skyhighfallguy -

Some interested party - eg. ICAO - or even a local authority could do a couple of "no fault" random check sim tests a year for every airline. That would give "people in high places" an idea of what is really going on re flying skills.

Politicians, their wives and children take airplanes too ...

[parkfell]

Clearly the competency testing following the accident has revealed some interesting results. I think their current TRE/TRIs should have their LPC/OPCs conducted by the Regulator until further notice.

Random observations when line pilots have their six monthly recurrency simulator checks are also necessary. This must include a good measure of teaching interesting situations from which a lot can be learnt.

The previous year's MORs will provide a rich source of scenarios. Just requires a bit of imagination and thought.

An interesting one ( a golden oldy) when I was on Saab 340 was ICING and the behaviour of the AP.
I was lucky as a Saab TP involved in Saab icing trials ( when the ATRs did not cope with icing in the USA) supervised by the FAA, often did my six monthly sim checks. I learnt a lot from him.

[Valdiviano]

Pardon my ignorance. Could the C C / third pilot have pulled the PL back?? And from then on things went pear shaped?

[Hotel Tango]

MPN11: Yes, but there's only a very minute fraction of passengers who read PPRuNe. So as I said, the majority are simply not aware.

[Uplinker]

Notwithstanding the actual cause of this accident, which remains to be determined; I have thought for some time - and it has been touched on here - that all LPC's should be conducted by TRE's from ICAO or some other suitable neutral agency - not by TRE's from the pilot's own company.

Examining by some company TREs is top standard, but in other companys, it seems to be very poor.

OPC's could still be conducted by company TRE's, but LPC's should be examined by TRE's entirely separate from the company, and unknown to the candidates, otherwise low standards might be allowed to prevail. An airline has an economic interest in keeping training costs to a minimum, and this could lead to substandard line flying and substandard pilot skill levels. Think about the recent crashes where pilots have made totally inappropriate control inputs when approaching a stall, or failed to monitor their airspeed, or identified the wrong engine etc. What is the cause of these examples of poor flying? It generally seems to be poor training and/or poor testing.

Company TRE's are checked by the authorities, but are then allowed to conduct LPC's autonomously until their next check.

I do of course realise that this would need a complete redesign of the logistics and economics of LPC SIMs, but I would have thought it would increase standards and safety.

[clunckdriver]

For those sugesting that a few of us from the industry could influence change by joining forces and talking to the regulators, I have bad news for you. In the country that I live and fly in the regulator is a major part of the problem, along with totally unqualified Provincial employees who have been able to hijack the training standards and flight training industry, promoting the dumbing down of training and causing huge monetry costs to the industry, all this done on the watch of the previous director of flight training who in retirement now thinks what he has done "might have been a miss- step". Now we have a Minister of Transport allowing of- shore pilots to fly Canadian aircraft without the required training and qualification required by our own regulations! {Having heard/witnesed one of these crews in "panic mode" a week ago when the weather was a bit claggy, we had in fact diverted, I just cant imagine what their background/training is having heard and witnesed their perfomance, in what was an almost normal Canadian Winter event}The regulator in this part of the globe is now looked upon as a bloody joke and have not attracted the right folks to join them in many moons, in fact of the five employees I had to fire years ago, four are now "inspectors". The only thing which will change whats going on is the insurance industry, and a major house cleaning of our Civil Service, Im not holding my breath for this to happen!The rot in pilot training and standards can, in this part of the globe, be laid at the feet of the regulator, untill qualified, independant folks are hired into a broken system, these sad events will not stop, the race to the bottom is a world wide problem, not just an Asian one.

[lomapaseo]

Slippery Pete

If this is simply as it appears... Autofeather #2 (perhaps ATPCS error, doesn't matter) followed by crew pulling torque off and eventually shutting down the operating engine, then the lesson to be learnt is very simple.

Why the #### are these things being shutdown close to the ground? At one turboprop operator I worked for, they were adamant the shutdown with a V1 failure was to be done at acceleration - sometimes as low as 500'. It was mind bogglingly stupid, but it still happens in turboprop sims the world over.

The only reason a shutdown should be actioned so low is for engine failure followed by failure to auto feather (a desperate situation indeed, yet one which had NEVER occurred since type certificate issue, worldwide, on the airframe I used to fly).

The case of a fire may also warrant an immediate shutdown, but should be with fire handle and fire handle alone.

Manipulating power levers and fuel shutoffs just after takeoff when one propeller has auto feathered and the aircraft is still completely climb-able and controllable is just nuts.

That's why these damn things have auto feather in the first place.

If it's climbing, sit on your hands and keep it flying. Anything and everything else can wait.

I hope desperately this was not a case of shutting down the only engine which was developing power.]

Agree ...... but

I'm still open minded that the aircraft having lost the thrust from one engine may have been continuing to lose flying performance from as yet the unexplained symptoms from the remaining engine. The crew may have reason to believe that they could only regain the full power on the remaining engine by restarting it.

This is only speculation on my part but surely it should be vetted in the onward investigation

[ZFT]

For those suggesting that a few of us from the industry could influence change by joining forces and talking to the regulators, I have bad news for you. In the country that I live and fly in the regulator is a major part of the problem, along with totally unqualified Provincial employees who have been able to hijack the training standards and flight training industry, promoting the dumbing down of training and causing huge monetary costs to the industry

Rest assured it's not just your part of the world. Many posters on this thread have been quick to criticise 'Asian' regulators but the principle regulators, FAA, EASA, Transport of Canada etc who should be leading by example are all guilty of dragging the industry down with ever increasing bureaucratic nonsense that adds no training value but does add significant cost. Costs that have to be recovered somewhere.

In our case we spend MORE time and MORE effort satisfying the regulatory requirements on CMS and SMS processes and procedures than we do on the OM and TM and the regulator spend more time auditing the CMS, SMS and associated Compliance Matrix than he does auditing the OM and TM.

It is somewhat ironic that today when the training tools have never been so good, the trainers (generally) so well trained that we seem to be having so many issues.

This particular accident may well highlight a regulatory issue with the manufacturers EASA approved delta course which (for marketing and/or cost reasons?) is quite limited with only 1 X 4 hour FFS session consisting of Severe Icing, Stall, EFATO, Go Arounds, both single and both engines exercises with 3 other days on low level training tools.

The FAA is even worse with NO regulatory requirement for ANY training to move from any 'Classic' ATR to the -600 and viva versa!!

What hope is there for the minor regulators that tend to follow (look up to) the majors?

So yes, I would concur that the regulator is a major part of the problem.

[skyhighfallguy]

To change the subject ever so slightly.

Last weekend I read that the authorities were to release transcripts of CVR and data from FDR on wednesday. This does not seem to have happened.

I must ask, what did they find out on the CVR that would be so damning as to preclude release of transcript? Was it rote? Something like: engine failure, FEATHER ONE.

Even though one was working OK?

It must be a public relations mess to have 14 percent of your pilots fail a written/oral exam AFTER a crash, and after you have warned them that a test is coming. Add to that a complete failure in the cockpit (Potentially), and the PR boys must be working over time.

[ThreeThreeMike]

No2 did a complete autofeather.Normal readings before AF and after.
The only signal to start the AF is torque below 18%.


ATCPS received a wrong signal.

Until the engine is examined I'd say your conclusion is premature. It's a bit of a stretch to make this statement based on a FDR trace.

Again, this is a moot point. Engines fail, and pilots are expected to deal with it. Regardless of the validity of the indication, the aircraft was by all indications flying normally and climbing on the other engine until the apparent improper manipulation of the flight controls.

[Smott999]

I don't know the veracity of this website or the translation, but if this is "all" there is in the way of CVR call-outs it seems pretty sparse doesn't it? The FDR notation of closing #1 appears to be the initial reduction, and there were several more reductions over the ensuing seconds which are not mentioned....eventually we get CVR callout re #2 flameout....by this time #1 is shut down or nearly so....


ALL 10:41:14.6 GE 235 flight recordings start
CVR 10:51:12.7 Songshan tower issued takeoff clearance
CVR 10:52:33.8 Songshan request GE 235 Contact Taipei Approach
FDR 10:52:38.x Engine Warning (2)
CVR 10:52:38.3 The main warning sound
FDR 10:52:42.x Closed on the 1st engine throttle
CVR 10:52:43.0 A crew mentioned engine recovery (One engine crew referred to recover)
CVR 10:53:00.4 Both crew mentioned engine flameout procedure
CVR 10:53:06.4 A crew mentioned engine recovery (One engine crew referred to recover)
CVR 10:53:07.7 Members mentioned confirm engine #2 flameout
ALL 10:53:09.9 Stall warning sounds (Until 10:53:10.8)
ALL 10:53:12.6 Stall warning sounds (Until 10:53:18.8)
CVR 10:53:19.6 A crew mentioned Engine #1 already feathered and the oil pressure was reducing
ALL 10:53:21.4 Stall warning sounds (Until 10:53:23.3)
FDR 10:53:24.x Off the 1st engine
ALL 10:53:25.7 Stall warning sounds (Until 10:53:27.3)
CVR 10:53:34.9 Contact Songshan tower crew call “mayday mayday engine flameout”
ALL 10:53:55.9 Stall warning sounds (Until 10:53:59.7)
ALL 10:54:06.1 Stall warning sounds (Until 10:54:10.1)
CVR 10:54:09.2 Crew began to call engine restart (Members began to call again to drive)
ALL 10:54:12.4 Stall warning sounds (Until 10:54:21.6)
FDR 10:54:20.x Engine 1 Restart (Reboot the 1st engine)
ALL 10:54:23.2 Stall warning sounds (Until 10:54:33.9)
CVR 10:54:34.4 The main warning sound
CVR 10:54:34.8 Unknown sound
ALL 10:54:36.6 Recorder stops recording
ASC explained that the warnings started about 37 seconds after takeoff (at an altitude of about 1,000 – 1,200 feet )

[de facto]

OPC's could still be conducted by company TRE's, but LPC's should be examined by TRE's entirely separate from the company, and unknown to the candidates, otherwise low standards might be allowed to prevail.
of course realise that this would need a complete redesign of the logistics and economics of LPC SIMs, but I would have thought it would increase standards and safety.

I believe it to be a very good idea....for example Star alliance TRE should be going from one airline to the other...basic knowledge of company SOP and off you go.

[noalign]

The FAA is even worse with NO regulatory requirement for ANY training to move from any 'Classic' ATR to the -600 and viva versa!!Are you basing this upon a reading of both the FSB for the ATR and AC 120-53B, a particular operator's differences program, or what?

[skyhighfallguy]

Rotten Training.

Questionable Basic flying skills and fundamentals of understanding of energy management.

Terrible over sight by local FAA equivilent.

Money being spent to buy planes but not train pilots to a real understanding as well as proficiency in the art of flying in normal and non normal situations.

I would add this: is it proper to sell a gun to a 5 year old? is it proper to sell a complicated airplane to an airline that can't handle the training and repair? It makes sense to me that some countries, some airlines are not ready to handle things to high western standards. PERHAPS the answer is to wet lease planes and crews from the manufacturer who will bear all training costs and mx costs and responsbilities/liabilities for the wet lease cost.

[RatherBeFlying]

I suspect the Viscount was the first aircraft with autofeather. I saw lots of folks in the sim lose an engine and just keep on flying without doing much of anything.

Unless the engine was on fire, a restart would be attempted at height.

The pistons needed to be feathered manually to have a chance of climbing which put the emphasis on fast hands, but they came with an FE who often caught a sagging engine before it got seriously sick.

Too many CAAs still want to see fast hands. Maybe it's still needed for those piston twins still out there, but definitely not for turboprops with working autofeather and a 50/50 chance of ending up with no engines producing power:uhoh:

[Tu.114]

It seems to me that there is some exaggeration going on here at the moment.

It is true; most turboprops around at the moment have Autofeather, and it is also true that it works as advertised most of the time. In an engine failure after V1, memory items are initially limited to the two questions:

1. Is the propeller feathered?

2. Is there a fire indicated?

(3. Did the uptrim work on the good engine - type dependent)

Answering those just requires checking of the instruments and no manipulation of any lever. And if both conditions are fulfilled, there is no more to be done until acceleration and cleanup. Then the book is taken out and the lists are worked off. So the only difference to a jet is the positive need to have the propeller feathered.

Workload starts to get a bit higher if either of the two conditions are not met. This is not because of some authority wishing to "see hands fly" at all costs; the aircraft just needs to be brought into a condition covered by performance calculations by feathering the propeller and a possible fire needs to be fought (this, again, is just as it is on a propeller-less aircraft). No flying hands or frantic actions are involved; such a procedure can and indeed should be handled in a calm and proper way just like any other abnormal procedure on any aircraft there may be. There is always time e. g. for the PF to properly verify that the PNF has his hands on the appropriate power lever, condition lever and T handle.

Also, please do not forget the role of the manufacturer in creating such a procedure. It may well be possible for him to allow flying the aircraft with one windmilling propeller until acceleration, but if climb gradients are still to be met, this will require reducing the max takeoff weight by offloading passengers and other payload and therefore make the aircraft unsellable to airlines.

Just to show some figures: on the DH8-300, an unserviceable Autofeather was releasable under MEL. This meant that an engine failure after V1 would have required manual feathering of the engine, which would have taken longer than with the autofeather working. And this alone caused a MTOW reduction that would have forced me once to offload 30 of the 40 passengers on board AND everything that was in the cargo compartment, had I accepted this aircraft. With no feathering at all until acceleration altitude, the restrictions would even be more severe and I would be surprised if the MTOW still allowed taking fuel on board.

[Lonewolf_50]

Money being spent to buy planes but not train pilots to a real understanding as well as proficiency in the art of flying in normal and non normal situations. There are a few countries in this world who do something similar in the realm of military hardware. They purchase some pretty good kit but their training methods don't prepare their operators on how to use them. The results in that case become obvious in a rather grim manner. I had never thought to apply the analogy to air transport ... but am disturbed to see that this might be the case. :ugh:

[IcePack]

1/2 the trouble is that so many non pilots inc the CEO's & accountants, have such "chips" on their shoulders & consider pilots expensive premadonners. Flying is easy isn't it not like my job etc unfortunately it is not. On occasions it is the most demanding of jobs which needs continuous training & practice. But that would undermine those non flyers mind set of expensive premadonners.
This has led to using the aircraft to practise for the sim, which is the opposite for which sim's were invented for.
So give this crew a break. If they were at fault the onus falls fair an square at the feet of those who follow the perception that flying is easy and those check airmen who go along with that mindset.

[Slippery_Pete]

Tu.144

I agree with most of what you've said. The need in a modern turboprop with a V1 failure is one of monitoring, not throwing switches and levers.

As for workload when a failure to autofeather occurs, or when a fire and failure occur simultaneously... Can anyone actually tell me the last time a modern turboprop had this occur? Engine failures between V1 and MSA are very, very rare these days - couple this with a simultaneous fire or failure to autofeather... I simply can't remember this having happened to any airline turboprop airframe type, the world over, for the last twenty years. As for monitoring torque push on the live and auto feather status, let the PNF worry about it. Just fly the OEI attitude and look at the VSI. Either it's climbing like it should (autofeather and torque push have occurred) or it isn't climbing like it should and something is drastically wrong. The correct attitude and the VSI will tell you. No need for slick hands or fancy callouts.

Yes, autofeather failure or simultaneous fire and failure needs to be trained for, but let's keep it all in perspective. It's a terribly, terribly unlikely thing to occur at takeoff.

If it's flying and climbing, it's flying and climbing. Get the thing safely accelerated and cleaned up, burn the good engine to its OEI time limit before reducing to MCP, get it to MSA, accelerate some more... And then, with the AP on if type allows, two pilots can concentrate on carefully pulling the dead engine into feather/fuel cutoff.

I don't for a second imply that this is definitely what has happened in this case. However, regardless of the cause of this accident, the way turboprop crews are trained on this has really been bugging me for a long time.

[pontifex]

The statement that immediate action is required in the event of a fire indication at a critical flight juncture (like just after take off) is, in my opinion, bad advice. Firstly, it may be a false warning and, secondly, even if actually on fire a gas turbine is most likely to still be producing power. No action should be taken until at least 1000ft apart for the NHP to state the fault and the engine concerned and for the HP to positively confirm the diagnosis. The Thompson bird ingestion on rotate at Manchester should be usd repeatedly as an example.

[Slippery_Pete]

Absolutely pontifex.

If the fire indication is not accompanied by a complete loss of power, get yourself cleaned up and accelerated first.

The other good thing about a fire (if the aircraft systems and checklists are well designed) is you can completely shut it down and feather by simply pulling the illuminated handle, rather than messing about with power and/or prop levers. A lot less chance of getting the wrong one. Certification should be updated to require ONLY pulling a flashing fire handle and nothing else.

[Australopithecus]

Slippery Pete...

Broadly, I agree. But with the proviso which you alluded to: namely, that this advice pertains to modern aircraft only. Maybe. There remain sufficient CV580s, Electras, C-130s, HS748s, and their smaller cousins to narrow your emphasis to the more modern versions only, at best.

In the earlier generation of turboprops the acceleration altitude was typically 400', and that for good reason. I have had a few actual powerplant failures in T-56* engine/Aeroproducts 601 propellors to testify to the need for timely intervention. PW engines too. **But those were primitive installations (and times) compared to the engine/props relevant to this discussion.

* Allison 501-D13 in civilian application

The propellor makes a thrust loss so much more demanding than on a jet: the ability of a windmilling prop/engine to extract all the energy that the good powerplant is producing (made worse with acceleration) is not understood by the jet only guys, and their advice should be taken with a grain of salt, if in fact you can identify it as such. Not all transport aircraft are created equally, nor is all transport aircraft experience.

Anyway...lots of suppositions in this thread, not much emphasis on confirmation bias about a heavily taxed crew already concerned about No.1, then faced with an auto fx on No.2. Most accidents, properly considered, end up being a study in perceptions and indications. I don't expect that this one will be too different.

[Mach E Avelli]

I don't think that the acceleration altitude of 400 feet was chosen as a result of the poor performance of early turbo props, but rather was just an arbitrary number.
Because windmilling drag increases with acceleration, there is a very strong case for NOT commencing acceleration until AFTER the memory items of any fire/manual feather drill have been completed. Even on the much simpler jets, all too often crews in simulator checks make a right pig's ear of the drill by attempting to do memory items simultaneous with acceleration. The result is inevitably that flap speeds are exceeded and the optimum final climb speed is not established.
Wrong as it may be from a certification point of view, I tell them to do one or the other in sequence - either finish the memory items then accelerate even if it means the aircraft is well above minimum acceleration altitude, or if it is less urgent, complete the acceleration then complete the memory items in the final climb segment.
Where it gets interesting is if the failure/fire is introduced just as acceleration is commenced. It is very hard for crews to resist trying to do it all at once, rather than sticking with whatever has been initiated.
Although we train for the classic failure at v1, more emphasis is needed on dealing with failures at random times.
I refrain from comment on this particular accident or the airline's training regime until the report is finalised.

[silverstrata]

Ratherbe:

To many CAAs still want to see fast hands.


Or ....... have you ever been taught the 'engine failure circuit'?

When I went east I was told to leave everything, and throw it into a very tight 500' circuit and land. No checks, no shutdown. Invariably many pilots, who were not allowed to hand fly anyway, missed the final turn completely and landed on a taxiway or the apron.

I was horrified, but had to comply.

[sierra5913]

Incident: Transasia AT72 at Taipei on Feb 21st 2015, engine loses power (http://avherald.com/h?article=482218c6&opt=0)

Incident: Transasia AT72 at Taipei on Feb 21st 2015, engine loses power

Transasia Avions de Transport Regional ATR-72-212A, registration B-22806 performing flight GE-507 from Taipei Songshan to Makung (Taiwan) with 20 passengers, was climbing out of Taipei's Songshan Airport when the crew received abnormal torque indications for the left hand engine (PW127) suggesting loss of engine power, stopped the climb and returned to Songshan Airport for a safe landing 19 minutes after departure.

The airline reported that the aircraft is undergoing an extensive examination even though so far no mechanical issue has been identified and the indication is believed to have been false. The passengers were taken to Makung by a replacement aircraft.

[Toruk Macto]

Hard to imagine ?

[Mach E Avelli]

Loss of correct torque indication is not that unusual. Fluctuating torque could be anything from gauge or transmitter problems to damage within the engine.
Dispatch without torque indication would be a no go, so a return to major maintenance base would also be a smart move. It seems that the crew decided that it did not warrant shutting the engine down, or that would have probably been added to the report in typically dramatic terms. So, what is hard to imagine?

The problem is, any turn back these days is cause for all sorts of speculation and innuendo. Particularly when the airline concerned is already in the spotlight for its recent accidents.

[barit1]

I'd find it hard to reconcile torque fluctuation without some other parameters also varying - either core rpm & turbine temp (gas generator issues), or else Np (prop governor/control).

Torque fluctuation, by itself without other confirming parameters, is almost certainly a sensor or indication problem.

[sierra5913]

Incident: Transasia AT72 at Taipei on Feb 21st 2015, engine loses power (http://avherald.com/h?article=482218c6&opt=0)

On Feb 22nd 2015 Taiwan's Civil Aviation Authority reported that the engine was working properly, the sensor system however delivered false indications. Parts of the sensor system have been replaced, examination and testing continues.

Just throwing a theory out there, maybe the airline just got a bad set of sensors installed across a range of their aircraft and nothing was ever wrong?

Would a bad sensor(s) deliver the kind of FDR report that came out with the accident aircraft?

[no-hoper]

About the sensors from AVH:


By no-hoper on Sunday, Feb 15th 2015 21:59Z

@Anne. Indeed there is a small buckle for a couple seconds.I think it is related to the closing of the bleed valve.

I checked the wiring manual for the signal required to start autofeather: The signal of one
torque sensor (2ea installed per engine) via the autofeather unit and displayed as the torque pointer will start autofeather.

The MEL for a u/s sensor requires ATCPS off,same for the autofeather unit.
Note for both of them: select off to prevent uncommanded autofeather.

[arizona]

Unreliable torq indication may indicate upcoming problem.

Surviving eight engine failures with engines like deHavillandGoblin, Allison C-18, Lycoming VO-540, General Electric CT58, PT6A-50 and PT6T-3, I may say the TQ indication in four of the occasions did show unreliable and erratic readings a few seconds before any other instrument or whistle went on.

These four failures were all related to serious internal engine oil problem.

[PastTense]

Taipei, Feb. 25 (CNA) TransAsia Airways ATR 72 pilots who did not pass a competency test following the carrier's second deadly air crash in less than a year will receive a second test in mid-March, the Civil Aeronautics Administration (CAA) said Wednesday. The 10 pilots who failed the evaluation after a TransAsia ATR 72 turbo-prop plane crashed on Feb. 4 were suspended from flying and have been undergoing remedial training since the Lunar New Year holiday, CAA officials said.

Another 45 TransAsia ATR 72 pilots who passed the exam will be tested on a flight simulator in Bangkok by the end of February, and those who fail the simulator evaluation will also be suspended from active duty, according to the agency.

The airline currently has 13 other ATR 72 pilots training overseas, and they will be given the same two-round evaluation as their colleagues after returning to Taiwan, the CAA said.
Unqualified TransAsia pilots to be re-evaluated mid-March: CAA | Society | FOCUS TAIWAN - CNA ENGLISH NEWS (http://focustaiwan.tw/news/asoc/201502250008.aspx)

[hans brinker]

It has been 10 years since I went from turbo prop to jet, and I cannot remember the details. Also I flew the F50 and DHC8 and not the ATR. My questions:

What does the autofeather do? (I know the basis function but what else):
-what triggers autofeather?
- does it reduce fuel flow to the "failed" engine?
- is the "objective TQ" increase a power up trim on the "working engine" or just a adjusted position of the torq bug requiring manual power increase on the working engine?

It looks like at 02:52:35 pretty much simultaneously :
- MW ENG 2 (flame out warning)
- start of increase in Beta ENG2 (feather in progress)
-ENG1 Bleed valve close (more power available on working engine)
- drop in all engine parameters for ENG 2 (FF, NH, NL, ITT) without PLA ENG2 movement (so that is a big one, will an autofeather of a working engine lead to over torque or reduce fuel flow?)

Looks like an autofeather but before the torque started dropping of. (is torque the only trigger for autofeather?)


From there on it looks like the pilot started reducing power on ENG 1 (02:52:43-02:53:15), tried to increase power on ENG 2 (PLA2 increase 02:53:15), and ENG 1 shut off at 02:53:20.

My cent (two cents corrected for inflation since it has been 10 years of the props)
I don't think any of the indications were crossed, it would have been apparent during start.

To me it looks like while they were looking at the problem they kept reducing power on the working engine, all engine indications on ENG 2 are consistent with the PLA change and subsequent shutdown.

Because I don't know if the autofeather reduces fuel flow after it senses failure and tries to feather I don't know if ENG 2 failed with a working autofeather or if the autofeather system feathered a working ENG 2 BUT:
The pilots should know how/what the autofeather does.

I was always trained to use power reduction as a confirmation for the failed engine, if you get a stall warning after you reduce power the power should have been pushed up (followed by a sheepish chuckle and "darn, I guess it was the other one").

It doesn't really matter what was wrong with ENG 2, it seems clear the pilots shut down a working engine for no apparent reason. I would love a well translated CVR readout, seems appropriate considering the leaked/released FDR data (and required testing of the remaining pilots) pretty much hangs them already.

[Chronus]

NSTB ASRS REPORT NO 823457 of Feb 2009 involving an ATR72 reads as follows.

During takeoff, the #2 propeller went into feather. I aborted the takeoff and returned to the ramp. Maintenance told me to do a run-up with the Automatic takeoff Power Control System off, because he suspected that it was sending a wrong electronic signal. I did the run-up with the Automatic Takeoff Power Control System on and off and both engines were operating normally. I concluded that since the aircraft's electrical system had been reset, the situation was corrected. I discussed the situation with the First Officer and we both felt that it was safe to fly.
Events

Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
Result.Flight Crew : Rejected Takeoff
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors

[RHKAAF]

During a turboprop take-off, V1 could occur with 8,000 to 10,000 ft of runway remaining at an international airport. If an engine failure and a fire warning occured just after V1 ,would it not be prudent to cut all power and use the remaining runway for a controlled landing and shutdown if necessary. Just a thought from an old timer.

[Livesinafield]

What does the autofeather do? (I know the basis function but what else):
-what triggers autofeather?
- does it reduce fuel flow to the "failed" engine?
- is the "objective TQ" increase a power up trim on the "working engine" or just a adjusted position of the torq bug requiring manual power increase on the working engine?

On my type, AF is triggered from either the AFU or the Engine control, (at takeoff both) it is triggered by a torque decreasing below 25%, the feather pump will run for 30 seconds and cause the failed engine to be feathered , at the same time the EEC will schedule more fuel to the remaining engine and Up trim it automatically, the bugs move automatically and the needles will match within a few percent.

The AF doesn't cut the fuel

we get 2.5 minutes at this setting, as i said its a different type but similar engine (PW126)

[Sampan Angkasa]

You are a real wise old timer; I like the way you think.

However, anal retentive powers that be do not allow this prudent de isin making anymore. We must " follow the book ". Otherwise you have arm chair experts gunning for your six.

An f/o as PF touching down at 3001 feet beyond the threshold on a 14000ft LDA runway at well below MLDW will get the captain in big doo-doo, thanks to FOQA. No amount of explaining as to the stupidity of waiving off such a landing when all things under safe control will satisfy big ego FOQA hawks who just want to see you punished. They need " to be seen doing a great job " of taking others a notch or two to satisfy a target quota.

[Mark in CA]

TAIPEI — The crew of a TransAsia Airways ATR plane that crashed in Taiwan in February, killing 43 people on board, had shut off the working engine after the other lost power, a source with direct knowledge of the matter said on Wednesday.

http://www.nytimes.com/reuters/2015/07/01/world/asia/01reuters-taiwan-airplane.html

[RHKAAF]

In the " old days " the mantra was " Dead leg ....Dead engine "
Hard to imagine that this is not taught today.

[armchairpilot94116]

http://www.taiwannews.com.tw/etn/news_content.php?id=2763968

For what it's worth.

[Dave's brother]

Here's a link to the press release, which contains much more detail on the cockpit conversation, as well as links to some of the published reports.


https://www.asc.gov.tw/main_en/docDetail.aspx?uid=318&pid=318&docid=701

[fox niner]

8 seconds before impact:
PF said “wow pulled back the wrong side throttle” while aircraft was at 309 ft. with speed 105 knots.

Not only did they shut down the wrong engine, but they also realised that they had made a mistake.

[Redredrobin]

ATC time


Summary

1051: 39


GE 235 flights took off rolling line.

1051: 43


Monitor drivers (PM) call "No ATPCS armed" control pilot (PF) answered, "Well continue the takeoff."
(ATPCS: Automatic Take-off Power Control System)

1051: 51


PM calls "Oh there Ah ATPCS armed there."

1052: 01


The aircraft took off from the ground, after the completion of post-takeoff checklist and connect the autopilot began to climb at 1,000 feet by starting right.

1052: 38


Warning aircraft cockpit noise by 1,200 feet; Procedure "ENG2 FLAME OUT AT TAKE OFF" appears on the Engine and Warning Display (EWD).

1052: 41


Aircraft climbed through 1,300 feet, PF will autopilot lifted.

1052: 43


PF said: "I put the engine back to One", PM replied: "Wait a minute cross check" this time ENG1 throttle position record income from 75 degrees to 66 degrees.

1053: 00


PM responded: "Good engine flame out check" and went on to say: "check up-trim there, auto feather there."

1053: 06


PF said: "The number one back to" after ENG1 throttle is closed to 49 degrees. Meanwhile PM said: "Okay, now is to determine the 2nd engine flameout."

1053: 09


PF replied: "Good." ENG1 throttle position remains at 49 degrees. At this height the aircraft to reach 1,630 feet, and began to decrease speed 102 knots / hour.

1053: 13


Audible stall warning sounded and a stick shakers, PM said: "Good pushing back."

1053: 15


PF said: "shut"; PM replied: "Wait a minute ... throttle throttle." 1053: 13-1053: 15:00 ENG2 the accelerator pushed to the recovery of 86 degrees to 34.5 degrees ENG1 throttle (idle position).

1053: 19


PF said: "number one" and then said: "feather shut off." Meanwhile PM said: "The number feather"; after the stall warning and stick pusher action to start 1053: 27.

1053: 22


PM said: "okay"; PF then said: "uh number one."

1053: 24


ENG1 CL (Condition Lever) is close to the fuel shutoff position; 6 seconds after ENG1 propeller shown in the feathered position.

1053: 35


PM Matsuyama tower to declare an emergency engine flameout, followed in 1053: 46-1054: 04, the flight crew had two attempts connect autopilot, unsuccessfully, at the same time during the aircraft entered a stall condition.

1054: 05


PM said: "The two sides are not" two seconds after the PM said: "There is no engine flameout both sides gone."

1054: 09


Aircraft height of 545 feet, the speed of 105 nautical miles / hour, PF said: "The car again."

1054: 20


ENG1 CL leave fuel shutoff position.

1054: 25


Aircraft height of 401 feet, the speed of 106 nautical miles / hour, ENG1 of NH1 speed increased to 30%, while the PM said: "not open."

1054: 27


Aircraft height of 309 feet, the speed of 105 nautical miles / hour, PF said: "wow throttle closing wrong."

1054: 34


Aircraft height of 83 feet, the speed of 108 nautical miles / hour, ground proximity warning system "Pull-up" warning sounded.

1054: 35


Aircraft height of 55 feet, the speed of 106 nautical miles / hour, the slope increased from the left 10 degrees to 80 degrees to the left, then the aircraft position near the viaduct on the left bank of the Keelung River, and the aircraft hit the left wing tip of a viaduct by driving the vehicle and after another crashed into a guardrail and a viaduct viaduct's edge lights, fall within the Keelung River.

[Lancman]

In the " old days " the mantra was " Dead leg ....Dead engine "

Was he using his legs or was the autopilot in, to reduce his work load?

[highflyer40]

The article stated he took control BEFORE stating left engine failed

[Greenlights]

nowadays, more and more pilots do not know to fly the plane when things gro wrong. No surprising that some people still talk about pilotless a/c. :ugh:
If pilots can not do their job properly (meaning, they are there to manage a plan and to fly if things go wrong) no wonder why accountants want pilots be paid less etc...I don't say it's good or not, but from an outside perspective, if I was a person who would not know anything about planes and pilots, yes, I would wonder in what is the role of pilots. And I don't want to say it's only to fly from A to B when everythings go fine. It is more than that.
I feel sad and angry that more and more pilots can not recover from a stall or from an engine failure or when autothrust if off during final approach. Something we learn from PPL 6th lesson or first week of MCC. Basics.

[Volume]

In the " old days " the mantra was " Dead leg ....Dead engine "

Today the mantra for engineers is "reduce the pilots workload"
...which unfortunately also means "reduce the information the pilot receives"
In IMC that might even be a good idea, as pilots may not immediately understand that they have to "kick the ball" since they are so used to have a screen showing the horizon, but not the yaw motion... Also the simulator can not give you the real sensation of the yaw due to an engine failure.

Sometimes the automatics save your day, sometimes they kill you or at least mislead you, so that you kill yourself. There is no easy solution to komplex problems. There are only skilled and well trained people solving problems. The more basic an aircraft behaves, the easier to understand the situation. But sometimes the harder to deal with it.
In the past pilots failed to do the right thing, today they typically fail already to understand the situation.

[GlobalNav]

"In IMC that might even be a good idea, as pilots may not immediately understand that they have to "kick the ball" since they are so used to have a screen showing the horizon, but not the yaw motion... Also the simulator can not give you the real sensation of the yaw due to an engine failure."

As much as training has changed, the focus moving toward using the automation and away from flying the airplane, I find it incredible to think that pilots are not made quite familiar with engine out procedures.

Nor does it surprise me entirely that the pilots extinguished the wrong engine - but it SHOULD surprise me. The British Midland accident in 1989 is another example, I suppose there are others. But, it anything comes out of this, it should be an emphasis in training. There is just no excuse for letting this go on.

[Fox3WheresMyBanana]

Oh, there's loads of excuses.
Crap pilots are cheaper.
They don't complain because their jobs are at risk anyway, so you can treat them like dirt.
The planes are safer.
Sufficient of the travelling public don't care about anything except the ticket price.
Governments don't want to rock the economic boat by regulating businesses properly.

[Jet Jockey A4]

The ASC's report also showed that Captain Liao Jian-zong had failed simulator training in May 2014, in part because he had insufficient knowledge of how to deal with an engine flame-out on take-off.

"Wow, pulled back the wrong side throttle," Liao, 41, was heard to say on voice recordings seconds before the crash.

There appeared to be confusion in the cockpit as the two captains tried to regain control of the plane after one engine lost power about three minutes into the doomed flight.

Liao reduced the throttle on the working engine but did not appear to realize his mistake until it was too late.

He tried to restart the engines several times before a junior first officer in the cockpit said: "Impact, impact, brace for impact."

Those were the chilling last words heard on the data recordings, according to the latest report of the ASC's investigation into the Feb. 4 crash.

Seconds later the almost new ATR 72-600, which had 58 people on board, crashed upside down into a shallow river in Taipei after it lurched between buildings, clipping an overpass and a taxi.

Fifteen people survived but all three pilots and 40 passengers and other crew died in the second crash involving a TransAsia ATR plane in a year.

A source with direct knowledge of the report told Reuters on Wednesday the working engine had been shut off.

FAILED SIMULATOR TRAINING

The ASC report, which neither assigns responsibility nor suggests recommendations, paints a more detailed picture than a preliminary report released days after the crash.

Liao, a former air force pilot, began flying commercial aircraft in 2009 and joined TransAsia the following year. He was promoted to captain in August 2014 and joined the ATR 72-600 fleet in November.

He had a total of 4,914 flight hours on ATR 72 planes.

However, the report showed that Liao failed the simulator check in May 2014 when he was being evaluated for promotion. Assessors found he had a tendency not to complete procedures and checks, and his "cockpit management and flight planning" were also found wanting.

However, he passed after a second simulator check on June 29 and 30 and was promoted to captain, although similar problems were detected during training from July 2-10 last year.

Instructors commented that he was "prone to be nervous and may make oral errors during the engine start procedure" and displayed a "lack of confidence", the report shows.

Issues cropped up again during training for the ATR 72-600 in November, when an instructor said Liao "may need extra training" when dealing with an engine failure after take-off.

After the crash, Taiwan's Civil Aeronautics Administration put TransAsia's ATR pilots through oral proficiency tests on how to handle an aircraft during engine failure.

All but one of the pilots passed the tests, although some needed more than one attempt. The lone failure was demoted in rank to vice captain from captain.

[Tscottme]

I think most multi-engine flight instructors will recognize that starting to shut down the wrong engine is one of the most common mistakes in multi-engine training.

[GSeries_jetcrew]

I think most multi-engine flight instructors will recognize that starting to shut down the wrong engine is one of the most common mistakes in multi-engine training.

Tscott that is exactly right. I trained multi conversion guys for 10 years and it was hands down the most dangerous kind of flying I've ever done because people would simply panic and use incorrect rudder or close the wrong throttle.
I would have thought with auto-feather on the ATR you would be better off doing nothing and focus on target speed and climbing.

[Pucka]

There needs to be a fundamental change in the basic handling of EFATO/V1 cut.
1:fly the a/c.
2:400ftagl,announce the failure.
3:1000ft agl,crew cross confirm failure then STOP!
REVIEW!!
Action check list.
Burning holes or wet cockpits happen due to stupid errors mostly via rushed event managing. The key is to slow down and confirm with review.
This whole regulatory sim scenario for IR/PC renewals..base checks hasn't changed since 1975!!!!!!

[Oakape]

Quote:
Originally Posted by Tscottme http://www.pprune.org/images/buttons/viewpost.gif (http://www.pprune.org/rumours-news/555876-transasia-water-35.html#post9032651)
I think most multi-engine flight instructors will recognize that starting to shut down the wrong engine is one of the most common mistakes in multi-engine training.

Tscott that is exactly right. I trained multi conversion guys for 10 years and it was hands down the most dangerous kind of flying I've ever done because people would simply panic and use incorrect rudder or close the wrong throttle. I would have thought with auto-feather on the ATR you would be better off doing nothing and focus on target speed and climbing.

This is not GA & it certainly isn't ab-initio twin training. This is airline flying & all pilots should have these issues well & truly sorted out before they come anywhere near the flight deck of an airliner.

The old adage that you get what you pay for may well hold true in this tragedy, but it shouldn't be accepted by anybody when people's lives are at stake. It is not a restaurant meal or a piece of clothing that we are talking about here, but it would seem that human life is cheap & getting cheaper all the time. Profit is all many care about.

[Greenlights]

soon I take my flight for vacation.

When I see this kind of accident, I just pray that automatism and plane work very well, and the pilots don't have to take controls (except for t/o and landing, oh well).
Not even a touch with one finger. :rolleyes::rolleyes:

As a pilot, I am just worried now about "my colleagues" (if they slept, if pay to fly or not, if a next lubitz or not etc).
Funny that since I work in this field, I feel less and less confortable as a passenger myself than before !

[susier]

After the crash, Taiwan's Civil Aeronautics Administration put TransAsia's ATR pilots through oral proficiency tests on how to handle an aircraft during engine failure.

All but one of the pilots passed the tests, although some needed more than one attempt. The lone failure was demoted in rank to vice captain from captain.


This sounds a little off to me. Surely you don't get to be even a 'vice captain' if you can't handle a flame out situation?


Is there a desperate shortage of pilots in that part of the world? (Forgive me for asking)

[fox niner]

It is not a restaurant meal or a piece of clothing that we are talking about here, but it would seem that human life is cheap & getting cheaper all the time. Profit is all many care about.

Well, airfares for any typical flight are less than a quarter pounder with cheese and a milkshake. Or any medium-sized T-shirt with starbucks on it. So don't expect too much in return.

[akaSylvia]

http://puu.sh/iLTL9/0f69c605c6.png

I don't understand this exchange. What is the flameout check and is that where the confusion between the two engines started? Or was it an incomplete check?

[Tu.114]

There needs to be a fundamental change in the basic handling of EFATO/V1 cut.
1:fly the a/c.
2:400ftagl,announce the failure.
3:1000ft agl,crew cross confirm failure then STOP!
REVIEW!!
Action check list.
Burning holes or wet cockpits happen due to stupid errors mostly via rushed event managing. The key is to slow down and confirm with review.
This whole regulatory sim scenario for IR/PC renewals..base checks hasn't changed since 1975!!!!!!

On a turboprop, it is not that simple. You need to make sure that the dead propeller is feathered, or else You will not get the required performance and might not even reach the 400ft AGL in Your suggestion. In fact, if You have not flown a turboprop in real life, I invite You to try a ATR or DH8 sim when You find the opportunity. Then You will see the difference: a failed jet simply stops pushing while a failed prop starts braking. Heavily. So a V1 cut will positively require a quick (but not hasty) analysis of the situation immediately after gear retraction. If the propeller is feathered and no fire is indicated, one can and indeed will wait until acceleration altitude to attack the problem. In case of a non-feathered prop and/or an engine fire, there will follow a by-heart shutdown of the engine and if needed the activation of the fire suppression systems (with the relevant selections confirmed and verified by the PF, but performed by PNF). After acceleration, it will be QRH time and all selections will be looked over once again.

This procedure comes with workload much higher than in a jet facing the same situation. It is not only strictly required due to performance reasons, but has been performed in real life many times without any bent metal resulting.

However, I strongly doubt that the proceedings in the TransAsia ATRs flight deck were even close to what any book says. The best SOP will not help anyone if it is not followed.

[Selfloading]

After the crash, Taiwan's Civil Aeronautics Administration put TransAsia's ATR pilots through oral proficiency tests on how to handle an aircraft during engine failure.

All but one of the pilots passed the tests, although some needed more than one attempt. The lone failure was demoted in rank to vice captain from captain.


This sounds a little off to me. Surely you don't get to be even a 'vice captain' if you can't handle a flame out situation?


Is there a desperate shortage of pilots in that part of the world? (Forgive me for asking)
As one who pays to sit in the back, this does not fill me with confidence.

[Tu.114]

As a matter of fact, what is a "vice captain"?

I kind of doubt that this is an intermediate flight crew rank. Could it be that this is what Googoo Translate made of the Chinese word for a First Officer?

[glofish]

On a turboprop, it is not that simple. You need to make sure that the dead propeller is feathered, or else You will not get the required performance and might not even reach the 400ft AGL in Your suggestion. In fact, if You have not flown a turboprop in real life, I invite You to try a ATR or DH8 sim when You find the opportunity. Then You will see the difference: a failed jet simply stops pushing while a failed prop starts braking.

You will get even less performance by shutting down the live engine! Even with an unfeathered prop the aircraft climbs better than without any working engine.

Thus i completely agree that you should take your time to properly analyse the situation before rushing to action.

The turboprop myth of having to feather in a heroic blink should not be upheld religiously by proud prop drivers, it misleads others.

By the way, if you have not flown a jet: Even a jet engine has quite some braking action when severely damaged, especially on the big twins ....

[HPSOV L]

NTS or Autofeather systems work far more reliably than pilots under stress. Even in an engine fire scenario the biggest risk is arguably the pilot rather than the fire itself. And in the real world what are the chances that performance is really critical?
Sure, pilots need to know how to handle the worst case but change the emphassis to leave the damn thing alone until you're good and ready to attend to it properly.
The prevailing training system is not based on sound risk vs. reward analysis but ego driven, outdated belt and braces dogma rooted in piston era instruction techniques and empire building.

About time it was taken outside and given a good kick up the arse.

[Old Fella]

It is not only TransAsia pilots, or turboprop pilots generally, who mistakenly shut down the wrong engine. BM Flt92 accident at Kegworth also involved the crew closing down the wrong engine in a B737-400.

[Tscottme]

Oakape, I think the point of my pointing out that starting to shutdown the wrong engine is perhaps the most common mistake in twin-engine training, was not to suggest we all just have to accept it. The point I was hinting at was that it suggests this pilot was not proficient or had not mastered operation of his aircraft. Asian airlines are expanding at fast rates and it's not impossible for a fast-growing airline, in a fast-growing region, to not train as much as others or hold on to less than stellar pilots once hired. Reliance on automation and turbine reliability can cover for a lot of underlying pilot deficiency. We don't have info if this accident pilot ever had a genuine engine failure outside of a sim. Of course he had the license, and the training, and should have been proficient at the procedure. In every field, at all levels of proficiency, there are common mistakes. Decade after decade in field after field many of these items are persistent. It never helps to have fewer pilots than you want, or access to less-experienced pilots than you wish. Nobody suggests we should accept this.

The accident pilots may have been the best in the fleet/region/world and just had a bad day. I'm sure the accident pilots were much better pilots than I am. My background is in training and my initial thought upon seeing the video of the last moments of this crash were that it looks like a classic twin-engine flip after speed decay below Vmca. It turns out, as it often does, to have been crew screwup. The transcripts turn out to show it was a screwup AND not following procedures. Nearly all pilot screwups could be prevented by following procedures, which would catch screwups if followed. If the accident pilot had waited to pull the throttle/power lever back until the PNF confirmed which engine was failing and which throttle was to be pulled this accident would not have happened. Nobody is suggesting anything is acceptable. :ugh:

[DirtyProp]

The Capt. had almost 5000 hrs on type.
This is no peanuts. I would expect such mistakes to be made by noobs and trainees, not Captains with this much time.
Bad training or selection process?

[Australopithecus]

The LH seat pilot came from the military where I am guessing he flew single engine jets, then transitioned to civilian flying in 2009. 5000 hours on type is just doing the same routine hour 5000 times. In a modern turbine transport* most pilots will never see an engine shut down, so the only practice people get is in their sim rides...so after training you see a failure what? twice a year?

Maybe it was a bit of both: weak candidate/mediocre training. Its not like there is a vast pool of qualified candidates to choose from in that part of the world, and training programmes are only as good as the most knowledgeable and experienced pilot WHO IS ALSO CONNECTED POLITICALLY TO SENIOR DECISION MAKERS, as distinct from the ideal.

*contrast that to the big pistons which failed often...the world Constellation fleet for example had >1 shut down every day, and that was fewer than 500 aircraft in daily use.

Question for the ATR experts: Does the yaw damper agressively compensate for engine loss? What indications of yaw are displayed on the EFIS, and how prominent is such indication, if any? Is torque displayed for each engine? Or any other reliable power indications beyond just N1, N2 and temperatures?

[funfly]

Sitting in the cockpit hours is a lot different from 'flying' hours. I often wonder how many of the thousands of hours credited to individual pilots are ones actually flying an aircraft?

[Rwy in Sight]

funfly,

Then it could me more interesting to note how many emergencies they have handled.

Rwy in Sight

[Livesinafield]

I don't think it comes down to how many hours or experience someone has, to me someone flying 10 hours across the pond for 20 years is not really flying experience, its system management experience

End of the day these chaps unfortunately made an error from an event that probably took them by surprise, i don't think any experience in the world can stop you making a mistake, its all about training and procedures and it seems Transasia's is not up to the mark.

Sometimes in a TP EFATO there is not too much time to sit and look at things initially there is quite a bit that has to be checked, my Type will not achieve a climb at max weight with an Auto Feather failure so the prop has to be feathered fairly quickly sometimes you cannot get a confirmation from the other guy as he is maxed out controlling the yaw

There's a moment where you look down at the CL and just have a 3 second mental check yourself...easy to C*ck that up

[funfly]

Shutting down the wrong engine is not a unique event. I would have thought that in the event of an engine fie there could be a bloody big hand pointing to the lever saying "it's this one - shut me down"

[Chronus]

No Funfly even if you mounted one as big as the one Kenny Everrett, may he rest in peace, used on his shows it would not work. If it has to be some kind of human appendage, much better to use big feet, the bigger the better.
Surely you must remember the drill for twins, " dead leg dead engine ". Is this no longer valid, has it been replaced with chimes, gongs, bells and whistles. If it has to be so, then what about an ambulance siren.

[silvertate]

contrast that to the big pistons which failed often...the world Constellation fleet for example had >1 shut down every day, and that was fewer than 500 aircraft in daily use.



Things have changed sisnce then.

Firstly, we had a flight engineer on the DC7, whose primary job was looking after the engines. And flight engineers were a special breed, manufactured in a biological facility in Arizona. It was physically impossible to get them to break into a sweat, because it was not in their programming. If an engine was on fire, they would go back and check, rather doing something as stupidly rash as wrongly loosing 25% of our power, when we could only climb at 500ft/min on four.

Secondly, when something is an everyday event, you deal with it as such. Another day at the office. Another engine symbol in the logbook, to go alongside all the others. The real surprise was when you got to 10,000 ft with all four still running. That was a cause for much celebration - coffee with a booster and high fives from the loadmaster.

The only reason they built the Connie and -7 with four engines, is because there was no room on the wing for six. Modern engineers and accountants have forgotten that truism, and seem intent on hanging 400 tonnes on just one live engine.

A good idea? I think not.

[silvertate]

Surely you must remember the drill for twins, " dead leg dead engine ". Is this no longer valid?




Again, most avaition logical thinking has been thrown out of the window by the accountants. EFATOs don't appear on the bottom line, or the shareholder's report, so it is a trivial matter of little importance.

In the old days they knew such things were important, and so the 737 had the fire warnings and handles on the coaming, in the central field of view. But then they started adding MCP automation at the cheapest price possible, which meant no major redesigns. The result was the fire warnings and handles were moved to the aft center console, underneath the fuel cocks, where it is all but impossible for the PF to see what the hell the PNF is doing.

Was this a good idea? No, it was cheap. That's what the passengers want, and that is what the passengers have got.

[Lemon Grass]

I significant issue is still being overlooked. Why was a global restriction (quietly) issued in December 2104 on 'Engine Out Training, Testing and Checking associated with DC Gen fault on remaining engine' on 72-600 FSTDs?, subsequently (quietly) rescinded in April 2015!

[noalign]

Early in this thread there was a FDR sequence posted. If that one indeed was for this flight, it shows the event on engine #2 about 30 seconds after the Ground/Air switched to Air. It shows over 1000 feet at the time of the initial event. This event happened well after rotation and lift off. It has yet to be suggested as to the cause of #2 feathering and sitting there with an 80% NH. This was not an Engine Flameout at Take Off. Indeed it appears it was not a Flameout at all. It also does not show the spiked torque that accompanies a uncommanded PCU feathering, instead it looks like any ATPCS triggered event. But why?

[oblivia]

In the old days...

...people died far more frequently and pilots opposed the introduction of cockpit voice recorders. Things have changed for the better since then.

[Uplinker]

funfly Sitting in the cockpit hours is a lot different from 'flying' hours. I often wonder how many of the thousands of hours credited to individual pilots are ones actually flying an aircraft?


Too true.

As well as flying hours, I keep a record of how many landings* I've done, which as you imply, does at least give an idea of how much actual manual handling I've had.

Having said that, don't discount the planning work one does while sitting in the cockpit: to avoid CB's and considering escape routes from high ground or oceans etc. in the event of emergencies.



*Obviously the number of landings should be the same as the number of take-offs, but owing to the occasional bounced landing, I probably have slightly more landings than take-offs !!:rolleyes:

[Old Fella]

Australopithecus, not all Military pilots fly only fast pointy nosed aircraft. As a former Military and Civil Flight Engineer I flew with many Military and ex-Military pilots in both turboprop and turbojet aircraft. Some had flown only fast jets prior to joining the airlines. None of those with whom I flew ever gave me cause to question their competence or their professionalism. We certainly saw many more than "twice per year" engine failures in the Simulator. Engine shutdowns were more common on the turboprop aircraft but not exclusively so. Well trained professional crews, regardless of whether they are ex-military or only ever civil, will generally have the capacity to handle any emergency which is able to be resolved. "Hasten slowly" has always been the norm in any outfit with which I have been associated.

[silvertate]

In the old days...

...people died far more frequently and pilots opposed the introduction of cockpit voice recorders. Things have changed for the better since then.


Apples and oranges. In the old days, most pilots had a couple engine failures or shut-downs every year.

Requote: 'Engineering has changed for the better since then....'. Trouble is, I'm not sure that not getting any real-time experience has done much for piloting skills.

[Volume]

it looks like any ATPCS triggered event. But why?
I propose you read the preliminary report. Especially the "Airworthiness Group" part.
It was a faulty torque sensor signal line (a cracked solder joint) which caused the AFU to autofeather a perfectly running engine.

[PT6Driver]

This is not a case of harking back to the good old days, nor should we be sidetracked by the need to quickly shut down in case the autofeather hasn't worked.
This is a clear case of failure to follow the correct sops, the FCOM and the correct shutdown procedure.

The report shows us what the screen would be like in the event of an engine failure of this sort. It tells you what to do, moving the power leaver to idle is item number 12 on that list. So even if you forgot the memory items, the aircraft reminds you!
It even tells you which leaver to move (1or2)
Whilst an engine failure is not run of the mill and your heart will be in your throat, with adequate training this should not be a major problem.
Training and rigorously applied basic standards.

Of note though the EWD screen shows white for Eng1, this is a non normal display and could be the reason why Capt A assumed Eng 1 was the problem. Not excusing just pointing out a possible physiological reason for his actions.

Although I point out the obvious failures, we should look at the reasons for them. Never assume you are immune from making the same mistake.

Dirty Prop;
Although Capt A had nearly 5000 total time only 250 odd was on this particular type!

[fireflybob]

Never assume you are immune from making the same mistake.


Absolutely - never was a truer statement made!

[Lemon Grass]

...............OEB 29!

[neila83]

Well as we see from the report on BA, shutting down engines against procedure and without involving the FO isn't limited to Asian airlines, so maybe go easy on the 'cultural' aspects hey?

[noalign]

This should take you to the beginning of the AFU discussion. http://www.asc.gov.tw/upload/acd_att/02_Airworthiness.pdf#page=27

There is also this; http://www.asc.gov.tw/upload/acd_att/01_Flight%20operations.pdf#page=30

[armchairpilot94116]

The Final Report on this accident is out:

https://www.asc.gov.tw/upload/acd_att/ASC-AOR-16-06-001%20EN.pdf

[GlueBall]

Dangerous crew incompetence: Shutting down wrong engine. :{

[sitigeltfel]

Firefox is flagging that link as "untrusted"!

[noske]

The wrong engine mistake was already known from the preliminary reports. What struck me when reading the findings summary was this:
Captain A’s performance during the occurrence was consistent with his performance weaknesses noted during his training, including his continued difficulties in handling emergency and/or abnormal situations, including engine flame out at take off and single engine operations. However, TransAsia Airways did not effectively address the evident and imminent flight safety risk that Captain A presented.:(

Regarding the untrusted link, try this instead: http://www.asc.gov.tw/upload/acd_att/ASC-AOR-16-06-001%20EN.pdf

[ZFT]

The wrong engine mistake was already known from the preliminary reports. What struck me when reading the findings summary was this:
:(

Regarding the untrusted link, try this instead: http://www.asc.gov.tw/upload/acd_att/ASC-AOR-16-06-001%20EN.pdf

Who signed him off? They are surely responsible?

[alph2z]

They tried to restart the good left engine which had been wrongly shut down. This HP compressor had reach 50% when they crashed. With 10 more seconds they might have had enough power to save the flight.

[deefer dog]

GlueBall

Dangerous crew incompetence: Shutting down wrong engine.

I guess you have never sat in the back of a sim, or even sweated a drop while being checked while driving one in the knowledge that everything you had mentally rehearsed was going to happen?

I'll bet also that you didn't even read the entire report (which incidentally I thought was of a very high standard), did you?

Clearly you didn't get as far as page 112 because you had already determined, in your ever so simplistic thought process, that the pilots were incompetent. It seems though that there are many more of them (us) out there that do not own your piloting skill set.....

About half of the accidents involving turboprop aircraft in
the transport category occurred during the take off phase of flight. About 63% of
the accidents involved a loss of control, with most of those occurring following the
propulsion system malfunction during take off. Seventy percent of the ‘powerplant
malfunction during take off’ events led to a loss of control, either immediately or
on the subsequent approach to land.

Propulsion system failures resulting in an uncommanded total power loss were
the most common technical events. ‘Shut down by crew’ events included those
where either a malfunction of the engine occurred and the crew shut down the
engine, or where one engine malfunctioned and the other (wrong) engine was shut
down. Fifty percent of the ‘shut down by crew’ events involved the crew shutting
down the wrong engine."

I'm no statistician, but excluding you perhaps 50% of us pprune readers might also have done it.

[AerocatS2A]

Deefer Dog, those stats are referring to accidents*. I think most of us with adequate training are comfortable that we would not be part of the accident group and therefore not part of the 50% who shut down the wrong engine.

*Statistics need to be read very carefully in order to make sense of them. The section is poorly worded and I am not sure if they are referring to accidents or PCM+ICR events (engine failure combined with incorrect crew response). Either way, it is not suggesting at all that 50% of pilots would make a similar error.

[RAT 5]

Shutting down the wrong engine in a multi-crew cockpit could lead one to consider slack training. It might be in an atmosphere of 'rushing' and surely would be in an atmosphere of 'not confirming'. The latter can be caused by a training culture. Some QRH's (memory & non-memory) require PM to "confirm" any control which shuts down an engine. There is, of course, a danger of lip-service to this procedure, but, again, that can be trained out in a strong culture. It does seem a staggering statistic and one which should be addressed to find 'out cause'. Mind you, 50% of 2 is 1, so just how many, here, does 50% represent? I admit to not yet having read the whole report.

[GlueBall]

deefer Dog - After engine failure, some rudder input becomes necessary in order to maintain flight path, directional control, heading. Most multiengine students during basic flight training have learned the elementary principle of "dead foot, dead engine." This concept is so instinctive that a good pilot does not need to look at engine instruments to determine which engine has lost power, or in the case of a four engined airplane, on which side the power loss had occured. So I stand by my comment that this crew, especially the PF, was incompetent in the elementary task of identifying the inoperative engine.

[avionimc]

...elementary principle of "dead foot, dead engine." This concept is so instinctive that a good pilot does not need to look at engine instruments to determine which engine has lost power...Well, if you have a torque runaway or overspeed of some sort, the GlueBall method will lead to shutting down the good engine [running normally] :=

[GlueBall]

avionimc - the "dead foot, dead engine" technique is an aid in IDENTIFYING an inoperative engine; the actual shutting down of an engine is a separate sequencial phase.

[Chronus]

deefer Dog - After engine failure, some rudder input becomes necessary in order to maintain flight path, directional control, heading. Most multiengine students during basic flight training have learned the elementary principle of "dead foot, dead engine." This concept is so instinctive that a good pilot does not need to look at engine instruments to determine which engine has lost power, or in the case of a four engined airplane, on which side the power loss had occured. So I stand by my comment that this crew, especially the PF, was incompetent in the elementary task of identifying the inoperative engine.
Glueball incompetent`s a bit heavy. Yes blame does lie with him for shutting down the wrong engine, but he was not alone in such an error, the chaps in the Kegworth crash did just the same and they had the comfort of time and altitude to realise their error, but did they, no they did not. By the very fact that it happened yet again the lessons of the Kegworth crash could not have been learned. Just have a look at the check list, nothing about dead leg anywhere on it. So the blame does not lie solely on the shoulders of the unfortunate crew. Most are taught on piston twins, lethal on single engine out on t/0, and the dead leg dead engine bit is drilled into them at that stage. But once they move onto the big and heavy machines they leave all that behind for the sophistication of automated systems. In this instance it was the AFU that was the first element in the causal chain. An essential piece of kit for a large turbo prop twin, without which it would require both legs of an Olympic wrestler to feather the great big paddles and keep the thing right way up. I just wonder for the ATR, as to where the AFU sits, on the DEL or MEL. I`d be surprised if it is on the deferred.

[formulaben]

I was taught IDENTIFY>VERIFY>SECURE. In crewed operations, every one of these are CONFIRMED by both crewmembers out loud...

What I am having a hard time understanding is what the training captain was doing this entire time...it's almost like he treated it like a training session and kept his mouth shut.

[peterporker]

TransAsia Airways to suspend operations: CAA | Economics | FOCUS TAIWAN - CNA ENGLISH NEWS (http://focustaiwan.tw/news/aeco/201611210011.aspx)

If you think safety is expensive, try having an accident.

[WaiFei]

More info here


TransAsia abruptly halts flights - Taipei Times (http://www.taipeitimes.com/News/front/archives/2016/11/22/2003659749)

[armchairpilot94116]

Yes too bad. Put near 2000 people out of work. Not only compensation paid, but govt sanctions to punish the airline after it's two accidents in two years (reduced flights, no new routes for a year, etc) plus 7 quarters of red ink finally forced them into suspension of operations. Next stop: liquidation of assets.

Formerly Taiwan's oldest airline (which had a previous 30 years of cessation of flight though). They stayed relevant through their catering and ground handling arms.

[aviator's_anonymous]

Seems a bit dodge... airlines gives 1 days notice and suspends all flights for a day... Continues to sell holidays and packages even when they have known they were going to suspend flight.. If you look into the finances, you'll find KMT central investments holding company produces about 15% of the shares in the airline...(previous government power)... with them no longer in power and struggling for money, you wonder where the finances in the airline have been redirected to... looks like there will be some spare A320/A321 and A330s for sale now...

[slavis]

TransAsia Airways to be dissolved | Society | FOCUS TAIWAN - CNA ENGLISH NEWS (http://focustaiwan.tw/news/asoc/201611220006.aspx)

TransAisa Airways will be desolved.

[armchairpilot94116]

China Airlines to fly TransAsia routes - Taipei Times (http://www.taipeitimes.com/News/front/archives/2016/11/24/2003659881)

Taiwan handles these things differently ! China Airlines to step in and take over the Trans Asia routes and honor the existing tickets. The Govt will freeze TRans Asia assets to pay for these flights as well as compensate employees.

In other news Ci and EVA looking to hire Trans Asia pilots. Maybe the mechanics, ground crew, flight attendants, etc can also apply.

Oh and the Chairman restricted from leaving the island and being investigated (along with other execs) for insider trading.

[ZFT]

A good start. Now what about all their suppliers and other creditors. Strange that they only sold and leased back their ATR 600s last week in Dubai for example!!!

The CAAT and Taiwan in general is going to be assessed on how this is handled, and yes, I have a (6 figure) vested interest

[armchairpilot94116]

Ouch! I am reading losses widened from 1.1 billion TWD last year to this year's so far 2.2 billion TWD so management decided to close down while "assets exceeded liabilities". They own 11 of their 26 planes apparently . I don't know how the planes are valued at fire sale prices.

It was reported they owe banks at least USD 350 plus million. So it is going to be "interesting" how it is all going to pan out. Ci, which is largely govt owned (while EVA is not) has been drafted to go in there and honor the 100,000 or so already sold tickets and run the flights (at a huge loss to Ci I am sure, as it is unsure if Ci will actually see any money). The banks are rushing in to "secure assets" . It's a mess.

Good Luck getting the deposit back !!
http://www.taipeitimes.com/News/biz/archives/2016/11/28/2003660113