B-738 Crash in Russia Rostov-on-Don

[Toshirozero]

A 'leak' is a deliberate dissemination of confidential information into the public domain.This alleged leak is from where exactly and from whom?

The Federal Law N 198-FZ of December 14, 1995, adopted by the State Duma on November 24, 1995 and approved by the Federal Assembly for the establishment of the IAC will have within it drastic penalties for breach of security and confidentialty.

I'm sure the delights of an unscheduled residency in the Lubyanka would seem sufficient deterrent for any unauthorised release of information.

If RT has a copy of the transcript, then publish the part that has the notation, IAC ref number and timings.

if RT wont publish verification, then the press can fabricate anything, provide no justification for the source other than 'from someone close to the investigation', and then watch as the various comments and uninformed speculative theories ricochet about this forum. This unsubstantiated 'leak' has been republished all over the globe.

so far all we know is what was in the IAC press release issued yesterday, ie, the plane was airworthy. Everything else is just media driven speculation.

[Rananim]

We can only make assumptions here with the data we've got so far.
GA made quite early in 2nd approach.Other aircraft(Russian locals-they dont divert readily) have been diverting so we can assume wshr and turbulence on approach was a genuine problem.Now if they got a windshear warning,either predictive or reactive,they have to follow their recovery procedure which is to disengage AP AT and fly out of it with no config change.The report of GA was matter of fact so perhaps it was not w/shr but mod to severe turbulence with speed excursions(flap overspeed etx).When they pull up,the PF follows the extreme ANU FD command,they get the unusual attitude and possible speed decay and try to recorrect but overcompensate esp with that very powerful THS.
FD fixation is a known problem with new generation pilots who are trained to fly/use/trust/depend almost exclusively on automation.
Its a funny thing actually.Because automation is a great tool.It is of great help to a pilot.But know when to use it,when not to,when to see through a FD command and ignore it and when not to.That is NOT being trained.
Problem lies in the training department(political correctness-emphasis on procedure-use AFDS dont fly the plane etc),not with these pilots.If you fix one you can fix the other.
A conference to collate/disseminate data on this known problem(pilots cant fly anymore) would be advantageous to aviation safety.Those airlines who remain a beacon of hope for this industry should call it and changes should be mandated for the good of all.Not easy to accomplish.Southwest,Qantas and Lufthansa could lead the way.All 3 emphasize stick and rudder and airmanship.Have flown with one.2 of them never crashed.Training excellent.Other airlines have much to offer.Belgians traditionally value manual flt skills and "fly the plane" .Americans too.BA has much to input.
Conference could address other abnormals like fatigue,rostering(esp am to pm consec changes),SICK/UNFIT never ever questioned,qualities desired in CP and Flt OPs post holders,pilots back at board level(absolute must).When I saw the gentleman on the right at FlyDub conference,I instinctively knew this airline had major problems and they were all coming from top down.
Start at the top,and the problems down through the ranks will start to disappear.You have to get the right people at the top first.

[pax britanica]

The point the previous poster made about pilots on the board is an important and sobering question. Whether anyone likes it or not the pilot group in an airline-followed closely by Engineering?maintenance have the most impact on safety.Errors there can mean a crash with loss of possibly hundreds of lives and enormous costs for the airline. But on how many major airlines is anyone from either fraternity (apologies ladies nothing meant by it) actually on the board.

A few years ago-slightly tongue in cheek I e-mailed Easyjet and said I might fly on them now they had introduced booked seats but were they really as safety conscious as they were cost conscious . Needless to say I got a great corporate speak reply, safety is our first and overirding priority , highest standards etc etc . To which i replied that was reassuring upto a point but if it was really so important why did their corporate profile of board members not actually ahve anyone whose repsonsibility was safety of flight -they were all accountants, marketers and lawyers.

How many others are like that-its not a dig at Ez but it does illustrate the current corporate mindset that as regards running the company flight operations are not seen that important when the outside mind would think those functions were the most important. Time to get a voice from the flight deck back at the boardroom table i think

[notapilot15]

pax britanica

MX is #1 cost cutting target by management. You will see aviation analysts don't like airlines trying to keep MX/MRO in-house. Emirates Group relatively spends very little on MX and every pundit loves them. Avg age of fleet and extensive outsourcing (other than the bits shown on Ultimate Dubai) are contributing factors. Outsourced MRO vendors charge very little and turn around very fast. Both targets are not achievable with in-house MRO, particularly for heavy checks.

But can you guarantee your outsourced MRO provider has the expertise and really performed required maintenance? No way of knowing it because statistically aircraft reliability increased (sans B787) in recent years and bean counters has the numbers in their favor than engineering chief who want to keep it in-house.

So even av engineering giants like LH and DL are looking for cheap MRO options.

Sorry for the rant

[Vc10Tail]

If I was talking to the plane I would say to an adverse situation developing that seemed life threatening.."please dont do this"...not "dont do THAT"...the latter would imply I am commanding the kther crew..and as a FO I would be in a asking mode.."why are you doing that?"
How did these "final crew conversation" even leak considering the investigation team and analyses medium is under tight control?

From the video originally posted by Scadi I reckon the second a/c image emerged at a point in space behind the first.Could it gave looped on its back as Shaggy sheep suggested somewhere on page 25?Upset recovery gone wrong with not enough altitude to recover coupled with disorientaion due to the rapud g force transitions and somatography? perhaps aa a desperate measure to bring the nose down fast the Capt. might have put in a steep bank angle(naturally he would turn toward Port side (as the last video captured a steep left bank) not Starboard...and could this have been the action behind the "dont worry..dont worry..dont worry"(i know what am doing...in case FO quizzed it?)? Assuming the leaked conversation wasnt mambo jambo to quench the tabloids and shut up the public...And why would they reveal only the last few words and not everything from the time the approach was commenced???

I doubt if there was a jammed stab..there was just not enough warning and crew might have shouted something..and if jammed it mighy likely have jammed nose up as that was their previous normal flight condition on initiating the go around.Structural failure though possible was not pointed out in the mini statement following initial FDR analyses as aircraft was pronounced as mechanically sound.Severe Icing?Again unlikely as has been mentioned in earlier threads.

Multiple go arounds at night at those times in inclement weather have shown in the past accident stats to result in a high probability of an incident or accident.

[AerocatS2A]

If I was talking to the plane I would say to an adverse situation developing that seemed life threatening.."please dont do this"...not "dont do THAT"...the latter would imply I am commanding the kther crew..and as a FO I would be in a asking mode.."why are you doing that

But you weren't flying this plane. I've used these exact words many times talking to an aeroplane (and sometimes to myself). It's generally in minor annoyance/frustration. Just because YOU wouldn't talk this way doesn't mean no one else would.

Possibilities:

1. The words were directed at the aeroplane.
2. They were directed at another pilot.
3. They were directed at themselves.
4. They were never spoken and this leaked CVR is all bollocks.
5. Other.

[Icarus2001]

We can only make assumptions here with the data we've got so far.

Or you could wait.

[320goat]

Exactly. I think we have exhausted the data that we have. Time to lock the thread until new evidence comes to light, and then maybe one of our amateur investigators will be able to say..."I told you so in post #152!!!"

[Vc10Tail]

Exactly. I think we have exhausted the data that we have. Time to lock the thread until new evidence comes to light, and then maybe one of our amateur investigators will be able to say..."I told you so in post #152!!!"
Upto this point we are ALL "armchair investigators" (aka rumour mongers) in this thread...including yourself.If the kitchen is too hot....what do you do?

Speculation and leaks fuel further speculation and it might stimulate more insights or add to more nonesense.It is the reader's responsibility to filter what they think is relevant and what is ignorable. Patronizing others about speculation or other egocentric implications amounts to the same arrogance if not ignorance that leads to topic tangency and ego mania.Let us be mindful.

Let everyone have their say and contributions but less us not be too critical of others opinions untill we know facts from reliable sources to be able to form more solid arguments and conclusions please.

AerocatS2A. Your points duly taken but as you noticed that was just my opinion and hypothesis "If I was"but you managed to misinterpret as a definitive statement.No I wasnt the obe flying and neither were you We are both lucky to be here to hold a postmortem discussion on their behalf God rest their souls in peace I might add.Your views just because YOU offer them doesnt make trash of others.It is a free thinking forum is it not?At least we agree that the leaked CVR might very well be nonesense!But thank you for your expanded view on the same.

[Vc10Tail]

Thanks for your above post Toshirozero.

[Kulverstukas]

I'm sure the delights of an unscheduled residency in the Lubyanka would seem sufficient deterrent for any unauthorised release of information.

Do you believe that KGB will chase leakers, then firing squad will shoot them, play balalaika and feed remnants to bears at Red Square? o.O

There is a lot of people involved into this investigation. Also aviation community is quite close and rumors circulated inside amplifying with each circle. I think that this "second" leak about "pilots disagreement" based on "transcript" published by 1tv after preliminary reading of CVR.

BTW MAK published short report (http://cdn.aviaforum.ru/images/2016/03/754690_10fe971bd20ae07ef95e2333d49436a9.pdf) on accident (in Russian).

[Alice025]

Kulverstukas what an excellent find.
While curious ones are mastering Google Russian, from humanity consideration - I do an amateur translation of the significant bit. The PRELIMINARY survey of the accident (as it's named) states that from the height of 220m they went to the go around. On reaching 900 m height - ? it went wrong. say. (Translate it better, please, the technical name, from the report, about what took place at the 900 m height.) At that time they were in manual . mode.
When AP was disengaged - the report doesn't mention at all. Neither when it was ever switched on. Of other interesting things I spotted that the crew told the tower about two weather things observed by them - of the "wind shear on the straight line" - when they were about to start the first landing (exact time or plane location during that wind shear are not listed), and, next, about "slight icing" of the plane - when they were completing the first go-round and were at the height 2450 - and that the crew asked the tower for the permission to increase their height to 4550 m because of that "slight icing". Which was granted, and from that height, it appears, they began the second landing. The report states that both landing attempts were done with the landing course 218 degrees.

[Toshirozero]

well Kulverstukas, it is April Fools day. Do they have Bears in Red Square?

The point was the the veracity of these so called leaks. The information if valid can only come from a Federal govt employee connected to the investigation. I seriously doubt anyone in that process has 'leaked' anything. So, how does RT substantiate these 'CVR leak' claims? Furthermore, why does anyone with any professional aviation background not question how the news cycle works and how it is specifically geared to generate contentious and or spurious information which is then self perpetuating ad nauseam.

A B738, performing a weather related GA, stopped climbing and descended rapidly until impact with the runway. Understanding the aircraft performance related possibilities for the sudden change in attitude is not the same as wild speculation as to the cockpit conversations and possible contributing causes.

as for the Balalaikas and Bears, surely some Vodka would seem appropriate?

[Avenger]

The full CVR transcript is unlikely to be released to the public domain, I don't think its worth speculating about arguments between pilots at this stage as the " official report" will condense the facts on a " need to know" basis..of course there are those outer playing the devils advocate, always will be :=

[Kulverstukas]

Toshirozero, there is a lot of people involved, as I wrote. Including experts working on temporary basis, different technical and assistance staff etc.

The information if valid can only come from a Federal govt employee connected to the investigation.

BTW, MAK isn't government organization.

Furthermore, why does anyone with any professional aviation background not question how the news cycle work

This (http://static.fjcdn.com/pictures/Science_8ed62c_1101628.gif)

[Kulverstukas]

On reaching 900 m height - ? it went wrong. say.

Just "on reaching 900m there was recorded HS travel to the nosedive position, as a result a/c from about 1000m begin descent and hit runway etc..."

[Toshirozero]

-Kulverstukas

whatever Russian Federal entity the MAK/IAC is governed by, it is the entity resposnible for ICAO Annex 13/Accident Investigation as Russia is a signatory to the Chicago convention: i.e., the MAK will publish the final report.

As for investigation confidentiality, refer back up to the previous reply. Balalaikas and dancing Bears notwithstanding, anyone who knowly released information concerning secure investigation data given the requirements of all participating States would be ill advised at best.

The MAK short report has enough info even with the limitations of internet transalation to discern that there was (quote)'900 m there is the movement of the stabilizer on the dive'

So we can discern from this that the stabilser moved..but how? There are only three ways that can happen.

[klintE]

The full CVR transcript is unlikely to be released to the public domain, I don't think its worth speculating about arguments between pilots at this stage as the " official report" will condense the facts on a " need to know" basis..of course there are those outer playing the devils advocate, always will be :=
What do you mean by "need to know basis"?
Every important factor must be included in the final report.
And conversation between crew members in crucial moments is conclusive even if they say absolutely nothing.
So I promise you in this case we will see something similar to: PIC.AL - Image Hosting Made Simple (http://pic.al/BZc) As always
But before that happens, we don't really need CVR. We need the truth.
Three days after GermanWings crash in Alps french prosecutor said to the public, without publishing any documents: yes, we strongly suspect that it was F/O deliberate action. That's how it should be done.
Families deserve to know why their loved ones died.
Publicity need to know what happened to keep an eye on reactions from people and institutions responsible for safety. (Reactions aimed on prevent reoccurence ofc)

[aterpster]

Toshirozero:

whatever Russian Federal entity the MAK/IAC is governed by, it is the entity resposnible for ICAO Annex 13/Accident Investigation as Russia is a signatory to the Chicago convention: i.e., the MAK will publish the final report.

Don't those ICAO requirements require the final report to be either in English or French?

[cessnapete]

Rananim
BA not a good example anymore, for manual handing practice.
Other than the B744, BA Sops on all new types, mandate full time auto throttle when A/P disengaged, and don't allow raw data handling on route flying even in good weather. LH for example allow manual sped control routinely even on A380, A/P off A/ T off..
Ragged speed control etc. exhibited by PF on the unlatched cowl Airbus incident shows lack of practice in manual handling perhaps.
Only practiced every couple of years in the sim.

[Kulverstukas]

anyone who knowly released information concerning secure investigation data

Agree, but unfortunately people feels at ease with non-military secrets (and military too) lately. There is no cases when somebody was severely punished for such things in the last 25 years.

[Icelanta]

Don't know about other companies, but I work for a large B744 ACMI operator...

During type-rating, done in-house, the first 3 sessions are completely devoted to manual ( raw data) flying, including all sorts of upset and stall scenarios.

Most approaches are A/P Off when conditions allow, also Raw-Data allowed.

Is this not done in other companies anymore?!

[Chronus]

It is perhaps unlikely that any QAR mem cards were recovered intact. Not only do these provide a lot more data than DFDR`s, they also help avoid incidents and accidents, particularly when it comes to non reported systems glitches.
I wonder what the company policy was in this instance.

[Toshirozero]

aterpster - read the annex. in the language of the state of occurence, with translation into at least one of the ICAO languages, usually English.

[PJ2]

Re, "I wonder what the company policy was in this instance."

Was the airline even running an FDM Program at all? Doesn't sound like it.

[lomapaseo]

It is perhaps unlikely that any QAR mem cards were recovered intact. Not only do these provide a lot more data than DFDR`s, they also help avoid incidents and accidents, particularly when it comes to non reported systems glitches.

Just as about as helpful as your computer windoze error log with no linking to the exact time and what your were trying to do at the time even though they often survive if you have the wherewithal to search for them.

[Chronus]

Re, "I wonder what the company policy was in this instance."

Was the airline even running an FDM Program at all? Doesn't sound like it.
Emirates say they do and if so no reason why Fly Dubai should be an exception I would have thought, but I stand to be corrected of course.

[SpannerInTheWerks]

the first 3 sessions are completely devoted to manual

That should last a lifetime then ... ?!?!

Just when I thought there were issues with pilot training and standards ...

I did over 2,000 hours of manual flying before I went anywhere near an automatic aeroplane.

There was a time when I happily boarded my holiday jet with my family and off we went without a care in the World ...

Now I seriously consider - are the pilots fatigued, can they fly an aeroplane and are they sane ... ?!?!?

And don't say this is scare-mongering after AF447, FlyDubai and GermanWings ... (oh, and maybe MH370 and the ATR that crashed inverted into a river).

It's rapidly getting to the stage where you have to think that if there's a failure of the automatics the result is likely to be an accident - whereas it used to be 'in the event of an emergency ditch the automatics and fly the aeroplane ...'.

Accidents are now being caused by pilot FAILURE rather than pilot ERROR ...

[seven3heaven]

PJ2 - Doesn't sound like they're running an FDM program? What makes you say that?
I can confirm that FZ do have an FDM program.

[peekay4]

I did over 2,000 hours of manual flying before I went anywhere near an automatic aeroplane.

There was a time when I happily boarded my holiday jet with my family and off we went without a care in the World ...
Ignorance is bliss...

Despite many problems, air transport is much safer today vs. all those years ago.

[PJ2]

seven3heaven, thanks very much for the confirmation. FWIW, I think it says something very positive about a carrier that runs an FDM Program.

[fireflybob]

Despite many problems, air transport is much safer today vs. all those years ag

Mmm depends what you mean by safe.

It's not necessarily the accident rate that counts but the reasons why the accidents (however few) are occurring. Quite a few in the last few years give cause for concern.

[The Ancient Geek]

Hmmmm - we have definitely improved safety over the last 20 years but most of the low hanging fruit has been picked by innovations such as TCAS and GPWS.

Fatalities per passenger mile have fallen consistently year on year but the number of fatal accidents has stagnated simply because the number of flights has grown. In other words we are a lot safer but we still have accidents grabbing the headlines.

The problem now is that the easier things have been fixed and we are left with the rare outlyers. The causes are varied and complex, often involving human factors.

The days of inventing a gadget to eliminate a risk are gone, we now need to tackle the unintended consequences of the technology which has improved safety.

To take a current example, there is a real risk that encouraging more hand flying could degrade safety rather than improving it. Nobody knows the answers to such questions.

[Alice025]

so. Thank you, Kulverstukas.
220 - 900 there was observed /we won't tell you how/ the movement of the stabilizer on the dive in the result of which - at the height of about 1000 metres, the aircraft went into dive


Next, our priority becomes. our work will be focused on


on the study of the work of the longitudinal aircraft control system and on the evaluation of the actions of the crew during the missed approach.

[Alice025]

The preliminary report ends by:


"Short-term recommendations:

- Deliver the information about the aviation accident to the pilots and technical staff, operating Boeing 737-800 aircraft

- Research the procedure of the missed approach - conducted in various conditions, from different heights, in manual mode of operation, at two working engines

- Add missed approach in various conditions, in manual mode of operation, with two working emgines, conducted from different heights, to the FFS (flight simulation training device) simulator training programme."
________
Accidents Investigation commission of the Interstate Aviation Committee

[porterhouse]

Quite a few in the last few years give cause for concern.
No more or less concern than in any previous chapter of aviation history.

[PBY]

When British Airways does not allow pilots manual flying, only once a year in the simulator, when most of the pilots cannot fly basic heading, altitude, speed witin the limits without flight directors, when management believes, that practising manual flying on a nice sunny afternoon could be dangerous, how the heck do you expect crews to manually fly a go around in case of automation fault?

[aterpster]

Toshirozero:

aterpster - read the annex. in the language of the state of occurence, with translation into at least one of the ICAO languages, usually English.

Thank you for answering my question. I don't have the annex.

[aterpster]

peekay4:

gnorance is bliss...

Despite many problems, air transport is much safer today vs. all those years ago.

Nonetheless, his points are well taken.

Now, the industry is upset by lack of upset training. (bad pun)

Yet, Boeing now disclaims disconnect of A/T in their latest birds.

There comes a point where the automatics need to be disconnected in favor of attitude instrument flying. But, my presumption is based upon competency in attitude instrument flying.

My presumption is probably lacking in some segments of the industry.

[PBY]

So British Airways management in their ultimate wisdom prevents pilots from manually flying the aircraft on the line. Than, just because they feel this measure is not enough to eradicate basic manual flying skills, they reduce the frequency from two sims a year to one sim. And I am sure it is backed up by some kind of a study, that it does not effect the safety. If this is happening in legacy carrier, what is happening elsewhere?
May be we should introduce a new profficiency called "attitude flying" and at least one pilot in the cockpit should have this qualification "unexpired"
May be a pilot error should be called management-pilot error. Because he pilot is usually dead after the accident and there is nothing to improve anymore.
But the systemic management incompetency could be improved upon.
And we would have less management-pilot errors in the future.

[anson harris]

So British Airways management in their ultimate wisdom prevents pilots from manually flying the aircraft on the line.

Absolute nonsense.

[PBY]

BA not a good example anymore, for manual handing practice.
Other than the B744, BA Sops on all new types, mandate full time auto throttle when A/P disengaged, and don't allow raw data handling on route flying even in good weather. LH for example allow manual sped control routinely even on A380, A/P off A/ T off..
Ragged speed control etc. exhibited by PF on the unlatched cowl Airbus incident shows lack of practice in manual handling perhaps.
Only practiced every couple of years in the sim.

Anson, read the quote above. You are not allowed raw data flying, unless you are on the experienced B744 fleet, where you still have aviators. Yes you are allowed to fly with flight directors and autothrottle. But for that you do not need pilots. You can train 10 years old to do that. The problem starts, if you loose all these goodies like an autothrottle and flight directors. And next time for the sake of clarification could you write more than just absolute nonsense? If you are BA and not on B744 fleet, when is the last time you enjoyed manual flying with FDs off Autothrust off?

[rainbow gravity]

This accident is strikingly similar to the Tatarstan Airlines Flight 363 B735 that crashed at Kazan, Russia in 2013. This is the graphic of the vertical profile in that accident. One possible reason for this profile is something I have seen in light aviation training - a confusion between stalling and zero g. If the push results in reduced g or slightly negative g, it can be percieved as the aircraft stalling, and so pic continues to push forwards to 'unstall' the aircraft. And the result is similar to that profile.
To your point, see the "pilot's perceived flight path" in the chart below.
Also disconcerting: The moment shortly before impact when F/O says: "Where are we going?".

https://aviation-safety.net/photos/graphics/20131117-0-G-2.jpg

[anson harris]

Anson, read the quote above

I'd read it thanks.

You know, not everything people write on PPRUNE is totally accurate. There's little point going into the details as you've obviously made your mind up, but BA allows pilots to be pilots, within the realms of logic and sense, far more than any other airline I've worked for.

[RAT 5]

If airlines, and BA is not the only one, forbid raw data flying, and discourage manual flying entirely, why is a raw data ILS still in the type rating LST? The XAA's deem it a necessary skill. If so then surely they should also encourage its retention. You do one with an LST and then never again in any mandatory test. You are forbidden, by your employer, under approval of the same XAA to retain this required skill. Why bother with the test in the first place if the same XAA does not enforce it throughout your career? Why not, at least, include it in LPC's instead of assuming some airlines will include it in their 'tick in the boxes' 3 yearly RST of flight controls? By doing that the XAA's would take a proactive role in reducing the dilution of piloting skills, if only by a smidgen.

[Old Boeing Driver]

Your presumption would be correct. IMHO

I remember the days of flying a PC check and the only time you would use the auto pilot was when the instructor/check airman was reloading glitches in the simulator.

If you could fly those simulators by hand, you could fly the plane by hand.

It is possible that the guys in this accident had lost some skills by using the automation so much.

Manual go-arounds are probably barely practiced these days in the sim.

Regards,

OBD

[ACMS]

Not true, we do them in our Proficiency check Sim, we alternate manual and automatic each Sim check, usually Engine out. True all Engines would speed things up a bit !!

Recurrent training sims cover raw data and manual flying skills as well.

[Old Boeing Driver]

I'm happy that you are able to do this at your airline.

I have been retired awhile, but after seeing a lot of the posts here, I think many rely (and teach reliance) on the automatics too much. Just an opinion.

Regards,

OBD

[Ian W]

PBY said:
May be a pilot error should be called management-pilot error. Because he pilot is usually dead after the accident and there is nothing to improve anymore.
But the systemic management incompetency could be improved upon.
And we would have less management-pilot errors in the future.

This type of error forcing already exists in Human Factors assessments. The Human Factors Analysis and Classification System (HFACS) actually puts Organizational Influences first in its 'fault tree' and second is 'Unsafe Supervisions' HFACS, Inc | The HFACS Framework (http://hfacs.com/hfacs-framework.html). The problem is not that it is not known, it is more that it is not chased up by the accident investigators as much as a mechanical fault would be. Recommendations by the investigation agencies for an aircraft system fix that is required are almost certain to be carried out. Recommendations from investigation agencies for organizational or supervisory changes are far less likely to be acted on.

[RAT 5]

One wonders if, considering how manual skills are not given priority by some operators, their published Safety Statement is correct in true spirit. Is it a case of words rather than deeds.
I did fly for some whose Ops manual said all the correct things about rostering & fatigue and many other items that seemed you were working in paradise, but the opposite was true.

[Fair_Weather_Flyer]

Thing is though, doing a go around in the 737 needs a mixture of hand flying and automation management skills, combined with mode awareness regarding the auto throttle and autopilot. It needs lots of training in the sim, yet two engine go arounds are very much neglected.

Just because a pilot can (or cannot) fly an ILS raw data or land off an NDB in a 40kt crosswind does not mean that they can fly a good 737 go around. It takes training and practice; pilots are not getting either. All about money at the end of the day.

[The Ancient Geek]

ISTM that some of these pilots need to spend a while in Africa hacking around the game reserves. Assorted wildlife, including pedestrians and bicycles, wandering across the strip is SOP and expected. If you dont go around at least once in a day you start to worry about what fate is storing up for you.

[Otto Throttle]

If the monthly ASR publication is anything to go by, FZ are reasonably well practiced at missed approaches, with several each month. As there are no corresponding ASRs to say that the engine fell off, logically these can be assumed to have been completed with both engines operating. Until now, no one had managed to crash, unless of course these are all the work of one insanely gifted pilot, or the FDM failed to register the corresponding aerobatics that we are led to believe accompany this difficult manoeuvre.

[Paranoid]

Seem to remember on my 14yrs on the BA777 many visual approaches in the Caribbean, Africa, TLV etc.Visual approach = no Flight Director.
Autotrottle on a FBW is very good, but was quite often manually 'assisted' when required.
Personally I tried to ensure 50% of my approaches (subject to sensible WX/ Fatigue limitations) were manually flown albeit most times with FD/AT.
Overall this fitted in with the BA policy at the time, and I feel enabled an an adequate standard of operation.
ATPL 20000hrs IRE/TRE.Retired.

[aox]

From the video originally posted by Scadi I reckon the second a/c image emerged at a point in space behind the first.Could it gave looped on its back as Shaggy sheep suggested somewhere on page 25?Upset recovery gone wrong with not enough altitude to recover coupled with disorientaion due to the rapud g force transitions and somatography?

I didn't think o, and I don't think it's safe assumption.

The camera is several miles upwind from the airport, and I don't think you get any impression of depth of field of view.

The landing light brightness changes a bit, notably a bit less bright as it pitches up at the start of the climb. Then as it emerges from cloud again it also isn't as bright, but I'd assume that's just because it's so nose down, rather than further away.

[Alycidon]

so, from a low energy situation, landing flap, gear down, speed around 140-150kts, this B737-800 pulls up into a loop?

Nope, laws of physics apply.

[bsieker]

[...] i.e., the MAK will publish the final report.


Toshirozero:

Don't those ICAO requirements require the final report to be either in English or French?

ICAO Annex 13 stipulates that the Final Report shall be sent to:


the State that instituted the investigation;
the State of the Operator;
the State of Design;
the State of Manufacture;
any State having suffered fatalities or serious injuries to its citizens; and
any State that provided relevant information, significant facilities or experts.


It does not say anything about publication. It is customary that the report is published, but not required.

As to the language, there is also no requirement, only a recommendation, which is not binding, that the report be in one of the ICAO working languages; these are English, Arabic, Chinese, French, Russian and Spanish.


Bernd

[aox]

I urge you to look at that video more closely.Refer to the serues of vertical lines on the light coloured building in front of the camera.

I'm afraid I don't understand the point you're making.

The aircraft is moving very slightly across the screen as it climbs, from left to right, angling towards the bottom of the 1 in the superimposed date caption. This suggests the viewpoint is slightly to the north of the aircraft track, not surprising when you look at the map. Then it emerges below the 9 of the date, crashing directly below the 9.

So two things have happened. The fact its downward path is not crossing the screen on the descent suggests it's now on a track altered slightly to the north, its right, of what it was.

But also, though this is rather less certain, if it had gone away from the viewer by doing a loop in cloud it would be more likely to emerge out a bit more to the left again wrt the reference of the date caption. But admittedly that assumption is less safe as a loop doesn't necessarily have to be perfectly wings level.

It just didn't occur to me, and I still don't view it that way.


Post 1085 Flight Path analysis might help you.

But that is a different matter. That is not about explaining how a loop happened, but instead it's about how the human balance system and brain can be tricked into misinterpreting the sensations and coming to the wrong conclusion that it was looping.

They've drawn instantaneously sensed gravity vectors on the real path that combine the effect of vertical gravity with the acceleration or retardation of the aircraft, then redrawn a hypothetical looping course that the body might be tricked into misbelieving when recalibrated by the assumption from most of non-flying life that gravity is vertical.

A while ago someone talked about some students under instruction being found to be very sensitive to negative or reduced g. They might mistake dropping feelings in turbulence for a stall, and then push the stick toward, then the reduced g increases the falling feeling, and they push harder, and might freeze. In some aircraft if their arm is then straight it can be tricky for the instructor to overcome them. I know someone slapped the pupil on the side of the head, and this made him let go.

Those sort of disorientating ffects are being explained for that accident, and what some people are suspecting for this one. Pushed too much, not pulled too much.

[vovachan]

Bottom line from the quick investigation update posted earlier is the HS went into a dive at 900 m. They don't know if this was deliberate or uncommanded.

[Alycidon]

Where did you get these low speeds from and landing flaps were they??It would be Flap 15 if already established in the Go Around and gear pissibly retracted and olane accelerating..very fast cobsidering the light weight they were at.And talk of physics laws..they apply to meteorology too and heard of chaos theory?Let the recorders explain those laws.You and I are just guessing our way through this riddle.

Most airlines insist on "stable approach" criteria being met at various points on the approach, the gear and flap would be selected accordingly.

Flap 15 by the way is listed as a landing flap option in the FMC, either way, stable approach criteria being the target, the aircraft would be in a low energy situation, I think I've only ever seen military fast jets transitioning from low energy to vertical flight, I would think a loop flown by a passenger jet off an approach rather unlikely.

The pitch down is the more probable scenario due both to somatographic illusion and the requirement to trim forward as the aircraft accelerates away from the low energy approach config.

Yes, you could say guesswork, but I base it on many thousands of hours flying the NG. As regards "chaos theory" I don't remember anything about it in ATPL meteorology.

[Sciolistes]

The pitch down is the more probable scenario due both to somatographic illusion and the requirement to trim forward as the aircraft accelerates away from the low energy approach config.

Except that, according to the FS24 data (2/10ths second sampling rate and known by personal experience to be reasonably accurate) fz981 had already been in a stable accelerating phase for a significant amount of time prior to the pitch down. The upset occurred at a calculated 220+ knots based on the groundspeed + headwind. The illusion scenario is so so very unlikely - I just can't see it personally.

[porterhouse]

The illusion scenario is so so very unlikely -
I think it is very likely, it brought down many 737/A320 in very similar circumstances, it brought down another 737 in Kazan, Russia 2 years ago. BTW, investigators almost never can determine what kind of illusion afflicted the pilots, they would usually simply state loss-of-control in flight for undetermined reasons. There are no black boxes in pilot's heads.

[Alycidon]

Sciolistes

Somatographic illusion is only one possibility, not necessarily the answer, but it is a well known phenomenon and with the power pitch couple it may cause the crew to either push forward on the control column or trim nose down or both. I'm not sure why you feel it is unlikely.

The subsequent low nose attitude and presumed high power setting would cause the aircraft to accelerate very rapidly giving the illusion of a pitch up, If the crew pulled the power back, this would make the aircraft pitch down even harder and given the extreme low nose attitude, the PFD would not look familiar to the crew and the pitch attitude would look unusual, the crew may therefore have relied on seat of the pants instinct and reacted to what they felt instead of using the information presented.

Flight simulators cannot replicate the somatographic effect, but instead, they rely on tilt angles to fool occupants into thinking they are manoeuvring such as accelerating down a runway while remaining firmly bolted to the floor.

There is no doubt that the aircraft was accelerating, very rapidly, toward the ground, as confirmed by the videos and the above mentioned fs24 data, laws of physics again.

I would tend to prefer the known science and lessons learned from the past and am not swayed by the unregulated data supplied by fs24 which seems just to confirm the obvious, eg, the aircraft started to climb, then descended rapidly.

[Sciolistes]

Flight simulators cannot replicate the somatographic effect, but instead, they rely on tilt angles to fool occupants into thinking they are manoeuvring such as accelerating down a runway while remaining firmly bolted to the floor.

Just think about this for a moment. They already did a go-around. They did second approach fully expecting to go-around again. The second go-around was completely and utterly normal until they are at clean speed and in a config that one can assume is flaps up. How in God's name can both pilots in a low authority gradient flight deck suddenly become so disorientated to the extent that they go from a climb to -15,000fpm in 5 seconds with no evidence of any attempt to recover (the opposite in fact)? It just makes no sense whatsoever.

Something else happened.

[mommaklee]

Hello again,

I was tinkering with acceleration vectors derived from the FR24 provided ADS-B data... a fearsome endeavor on several fronts! :ooh:

Using these, I took a first stab at the ascent angle the crew of FZ981 might have felt (which could be completely wrong as I am way out of my league as a meteorologist trying to calculate an aviator's somatogravic illusion -- nothing could go wrong with that! ;) ).

http://i.imgur.com/CjM8r1h.png

My methodology:
-- calculate the plane's ascent angle (simple right angle triangle trig) using the vertical and horizontal velocities (I created a second vert. velocity set which used the gps altitude changes in the last few seconds as the VV reported look to be off (I could speculate as to why, but that would be a different post)

-- calculate vert and horiz accel based on changing vert and horiz velocities.

-- add gravity (9.8 m/s) to the vert. accel

-- calculate the acceleration vector (as well as the not shown magnitude) based on H&V accel such that 90deg equals no aircraft accel, and 1g of fwd (and level) accel equals 45deg. (for example only)

-- Pitch illusion I estimated as: (90deg - AccelAngle + AscentAngle). I estimated this based on the lower of the two plots on this chart from the AIB:

http://i.imgur.com/MyEblSP.jpg

I would not be shocked if I made one or more boneheaded mistakes, and would be more than happy to fix them ;). I would be happy to share my excel worksheets.

I hope this is helpful,

Jacob

[Alycidon]

Something else happened.

no doubt, including but not limited to, various EGPWS/TAWS warnings, overspeed clacker, autopilot disconnect warning, speed trim, acceleration forces, a rapid arrival at the business end of the Yerkes Dodson curve.

[JPJP]

Your presumption would be correct. IMHO

I remember the days of flying a PC check and the only time you would use the auto pilot was when the instructor/check airman was reloading glitches in the simulator.

If you could fly those simulators by hand, you could fly the plane by hand.

It is possible that the guys in this accident had lost some skills by using the automation so much.

Manual go-arounds are probably barely practiced these days in the sim.

Regards,

OBD
The accident aircraft was equipped with HGS (HUD). It was not equipped for Autoland (fully coupled approach). As a result; the Go Around would have been hand flown. At the very least the autopilot was off, and possibly the auto throttles.

My employer uses the same configuration (HGS). All Go Arounds are hand flown. In the Sim, and in the aircraft. My point is this; The 737 not equipped with Autoland requires a manually flown Go Around. If the Autopilot is off during the approach, then the Go Around will be hand flown without auto throttles.

[olasek]

How in God's name can both pilots in a low authority gradient flight deck suddenly become so disorientated
I could be asking the same pointless questions like for example how in God's name 2 professional pilots end up taking off in a fully loaded 747 at night in perfect weather from a taxiway instead of a runway?. How in a hell is it possible? But it did happen and it was not a deliberate act, it was a crew error. Your "how in God's name.. so disoriented" is responsible for over 1600 fatalities in last 10 years, roughly 42% of all commercial airlines fatalities when accident was classified as LOC-I (Loss-of-Control-In-Flight) and many of them happened at night or dusk/dawn soon after takeoff, during go-arounds or approaches. If you don't understand this basic fact you really don't understand human factors in aviation. I suggest you go back in history and re-create some of those accidents where things can go very rapidly from climbing to -15000 fpm.

[PJ2]

Re, "how in God's name...", etc.,

As Sid Dekker writes in his, The Field Guide to Understanding Human Error, "What [we] think should have happened does not explain people's behaviour.", (Ch.5, p.39, Ashgate 2006)

[Timelord]

It can be incredibly difficult to interpret a HUD in a rapidly changing unusual attitude. I sim instruct on a HUD equipped military type, and the first action on disorientation is to transfer to head down (conventional) instruments. Has the civil world taken on this advice when it started to get HUDs?

[josephfeatherweight]

Timelord - yes, it is strongly advised for the reason you state.

[TOGA Tap]

I think that SOPs need to be changed in order to avoid the repeated crashes after go around. Crash sequence begins with the extreme uncontrolled nose up pitch angle which is spotted too late and overcontrol of the the nosedown correction resulting in extreme nose down dive at low altitude.

The SOP change attempting to break this chain is as follows:

At Take off at the Vr Speed the PNF announces "Rotate XX" (XX being number of degrees eg. Rotate 14).
So on take off it is just one word more added to SOPs.

At Go Around situation the PF announces his intentions with words "Go Aroud" and commands some configuration change eg : "Go Around Flaps 11" so the PNF knows what is going on and what is expected from him at that time.

The PNF then announces "Rotate XX" (Again the XX is number of degrees) and then continue as per present SOPs. The same words "Rotate XX" are used in both Take Off and Go Around.

This little addition to the existing SOPs would help fhe pilot flying focus attention on the relevant instrument indication pitch angle which is often neglected by pilots focusing too much attention at the Flight Director or IAS indication.Also the PNF would adjust his attention span to include the pitch angle.
This change would help to reach and maintain the approximate pitch angle required for the initial climb out.

Calling the required pitch on each take off would make it a habit to do the same at the moment of a go around when the aircraft is rotated from approach pitch to the approximate go around pitch angle.

[PJ2]

Go-around pitch attitudes vary within a very narrow band, usually 12.5 to a max of 20 or a pitch that yields the correct GA airspeed and keeps it there. Go-around pitch attitudes are a part of the certification process and when flown, are safe. There should be no need to specify pitch.

Experience would indicate however, that there is a strong and clear need to make a call when pitch or speed are either above or below SOP limits.

FDM Programs should be able to help trend what kind of GA performance an air carrier is getting from its pilots, and train accordingly.

Also, go-arounds from altitude, (not at/near minima) require slightly different handling, and a pitch attitude appropriate to the circumstances, not an "SOP-specific" pitch attitude. Here again a call-out is already mandatory in SOPs when any parameter is beyond SOP tolerances.

[framer]

I don't like a mandated call out of X degrees. What if I don't want to fly 15 degrees for a valid reason ? A much better idea would be to recognise that as an Industry we are training more subjects in a shorter space of time to candidates with less hand flying experience, and to allow for the new/extra sunjects in our training system. ( an annual handling sim?) In addition to appropriate levels of recurrent training, legislating to respect a pilots circadium rhythm to some degree when building rosters is also necessary. Mandating another word isn't addressing the problems, it is showing a lack of understanding about why Air Transport is generally safe.

[Capn Bloggs]

I agree with Framer and PJ2; an extra "pitch" call is not required. Aeroplanes should not be flown by mouth. The crux of the matter under discussion is that pilots sometimes can no longer fly the required manoeuvre, which is, get the nose up and control the speed with pitch until leveloff, then control altitude with pitch and speed with throttles (if the ATS isn't doing it). Simple stuff, really. The more bandaids we put on (eg more standard calls) the more we are merely covering up the underlying problem and eventually making it worse.

As an aside, the "Go Round" call is an FMA readout, not a call of intent. A call of intent would be "Going Around".

[PJ2]

I hope "TOGA Tap" picks up on the feedback regarding the suggestion, offered 'as intended' - the suggestion shows some thought about the problem, which is always to be encouraged, particularly today where thought and airmanship appears all but discouraged in favour of auditable training and standards results instead of thinking like a pilot. There is an aspect of mentorship here that I hope is not missed.

[framer]

That is a very good point PJ.
The kind of maturity required to hold that view point, combined with significant Air Transport Command experience, is what is required at Regulator level and board level in order to see any meaningful change.
(nb I don't profess to have either of the requirements but am working on it:))

[Icarus2001]

TOGA Tap, whatever the solution, it is definitely NOT more words spoken by anyone on the flight deck.

[gatbusdriver]

We have a call that should be made in case of incorrect action 'PITCH PITCH'

[PBY]

Airbus training in Toulouse does not train pitch and power at all in their syllabus.
They are very much FDs and Bird dependent. They also do not teach unusual attitude recovery. They only introduced stal recovery into their manuals after AF447 crash. Until than it was not thought at all. But I thought that the Boeing group training was much better as Boeing is not such a forgiving machine as an airbus with its protections. I am starting to realize that the airlines inability to teach basic "pitch and power equals performance" is a wide spread phenomenon through all airlines and types. Having said that, I have met few capable instructors in my flying carrier, who could teach the basics. But most airlines brush basic training off with the words, "They are airline pilots, they must know how to fly".
If pilots do not have basic scanning ability and in all their manual flying they only follow flight directors, while not seing through it the actual performance, how can we expect these
pilots, who were not exposed to proper training for years, to perform well while they are under stress, tired and at night? If the heads up display flight directors show them to dive down due to basting altitude constrain, of course they will blindly follow it. They are used to flight directors showing them the way. Flight director is the real PIC on the aircraft.
With few exception, every sim I teach, I have to revert to teaching basic attitude flying. I disregard the rest of syllabus until people can fly. And they usually improve quickly and within one hour they are proficient. But why am I the only guy as far as I know, who does that? Could somebody else incourage me and tell me they also teach basic raw data flying in airlines? Why do we constantly keep repeating the mantra: Fly Navigate And Communicate but do not teach flying skills? Why do most airline pilots who start to criticise me do not know the difference of scanning ability required for Raw data with FDs off and Authotrust off" as opposed to following flight directors with autothrust on? Those who are the once saying pilots must know how to fly are usually the once who cannot do it. And they usually take it out of the syllabus as they are the management.

[grizzled]

PJ2

Good to see the return of your always professional, always useful, input on this forum. So many of the old time PPRuNers have given up on this site...

grizz

[G0ULI]

Perhaps it is time that pilots were run through a couple of simulator sessions after a prolonged period of wakefulness. The aim being to see how they react to problems while fatigued.

The sessions would be recorded and analysed after a decent period of rest.

Some reinforcement training could then be tailored to address any issues and a further test conducted.

While this might not solve all the problems, at least pilots would be aware of their individual limitations and potential problems that could arise when they were fatigued.

[porkflyer]

Time to go the FAA way. Before line 1500 hours if stick and rudder flying as FI or in GA.Too many theorist..too many useless briefings what saves the day u is often basic flying skills implanted in a well rested pilot.

[de facto]

Proper management,adherance to SOPs,understanding of your limits and those of your colleagues,being mentally ready for a go around especially when complex,clear and appropriate/relevant briefings ,and finally but not the least,manual skills that allow you to disengage the automatics when they are not doing what you commanded them to or expected them to,without shedding a sweat.

[dr dre]

Time to go the FAA way. Before line 1500 hours if stick and rudder flying as FI or in GA.Too many theorist..too many useless briefings what saves the day u is often basic flying skills implanted in a well rested pilot.


Notwithstanding that the pilots in the crash that prompted the US Congress decision (not the FAA) to go with the 1500hr rule (Colgan 3407) had the time before joining the airline, including one as a flying instructor. Doesn't matter what your background is, being fatigued out of your mind will cause your stick and rudder skills to be non existent when the proverbial hits the fan.

[Deep and fast]

In my view, the problem is that the XAA the world over have taken a more distanced view from the pointy end. It's now a paperwork excercise and they audit the paperwork.
What about getting out on the line and talking to the crews and get under the skin of the operation and not just an arse covering paperwork excercise.

As for fatigue, I think certain airlines are testing new waters with regard to human endurance, like an airline version of the Japanese game show.

Legal or not, airlines do not care about fatigue in the real world as long as it's not on too much paperwork and the planes keep flying. Captain dies, hell just hire another.....
Some of my family where on a certain Middle East carrier recently and I was glad to hear they had landed, I know crew there and the hours they work.

Shocking really.

[TOGA Tap]

Adding new words in the standard and well established SOPs for the go-around might be an overkill - I agree with that.

Adding a few words with the same content and with the same intent in the approach brief would be much easier thing to implement and would serve the same purpose -
Example "... in case of a go -around ... I will pitch up to XX degrees and HOLD it there "- that would 'recharge' the PF's short term memory.

[fireflybob]

We get good at what we practise on a regular basis e.g. ILS approach.

How often do we fly an all engine Go Around?

That said an all engine Go Around flown by a well trained and current pilot should be a routine manoeuvre. But it's not down to one person. The monitoring pilot has a big role to play especially when the crew are not at their best due to fatigue etc and a well flown GA is more assured by good crew coordination/teamwork and planning/briefing.

[RVF750]

Yes it should. But unfortunately, the mindset and SA is just not there is some folk, due primarily to lack of practice...

When I have to go around, I prefer manual, because depending on a lot of things, I know how much thrust I need to achieve the flightpath I want. Yes, I disconnect the AT and push to what I want. If I have an early GA it can be a very gentle manoeuvre, and it's under my control.

Blindly following SOP, and just pushing buttons removes the flexibility. Totally. It rains out the airmanship of generations past.

6,500ft Approach platform towards an ILS and a 6,600ft Go around altitude. What if you miss the GS and need to discontinue? I've seen very confused folk pushing the TOGA button and expecting to go for it.... Only they're at F5 and level.....

Absolutely no idea what to do, and that's totally a result of training and lack of experience.

How to combat this kind of outcome? That is the question. Beasts me. I left them to it.... and got the hell out of Dodge!

[OK465]

It can be incredibly difficult to interpret a HUD in a rapidly changing unusual attitude

(I don't know about 'incredibly' but certainly dynamic).....

Since FZ evidently utilize HGS at times I'll add another comment about about HGS use here in TOGA that fits with the pitch attitude 'call' discussion.

For both takeoff and go-around the HUD displays a dashed line that represents target pitch attitude for the maneuver so the raw information is already there.....however command steering (flight director 'ball') is for the FPV not the 'attitude symbol', i.e. 'boreline'), both 'ball in the FPV' and 'boreline on the dashed line' theoretically resulting in the same flight profile.

Normal phases of flight the FPV sits about 2-6 degrees below the pitch symbol. At 0.0-0.2g the FPV might end up slightly above or nearly aligned with the pitch attitude symbol. I've observed various responses to this.....

[PJ2]

OK465, re your comment, "I've observed various responses to this.....", I'll bet you have! In fact at one time the Airbus FCOM did not permit the use of the FPV on the go-around due to possibly-confusing/conflicting data (due to aircraft inertia), that may inadvertently be followed in a manual go-around.

I believe that's changed and now when the thrust levers are set (or moved to TOGA to trigger the GA programming then brought back), the FD automatically switches to the SRS, (Speed Reference System) mode. The manual further emphasizes that lag in the FD system may initially occur and that pitch attitude is the primary parameter for the go-around manoeuvre.

[Jwscud]

Very interesting comments on HUD flying. I have precisely zero HUD experience, as I imagine is the same for the vast majority of non-military pilots.

How is it trained? What sort of material is available to flight crews to assist them?

I know of colleagues moving to the 787 who are not keen on the ball/bird flight director presentation as it reduces flying to even more of a computer game with more distractions than a PFD with cross bars.

I believe it was RAT 5 in discussing the Air Asia accident who came up with the excellent suggestion of flying with FDs off whenever the autopilot is in use to facilitate knowledge and monitoring of normal pitch attitudes and I think it merits serious consideration.

[Vc10Tail]

so, from a low energy situation, landing flap, gear down, speed around 140-150kts, this B737-800 pulls up into a loop?

Nope, laws of physics apply.
Your definition of low energy is a bit wanting.TOGA thrust and GA configuration is hardly "low energy".I never suggested any pull ups.There might have been a pitch mistrim,stab runaway or jammed stab (if icing was a scenario) which coupled with TOGA thrust and vertical windshears sll might have produced a pronounced pitch up and fighting that by pushing the control column or overtrimming downward ("flying by trim" as primary input..which is non recommended procedure.Ref to link: Pitch trim - poorly understood? ) might have caused a further upsupset.No FDR and no CVR leads to no useful conclusion no.msyter how many hours some of you here claim to have on 73NG.This is an accident that demands expert analysis.Let us be patient..word will surface..given time.

[OK465]

the FD automatically switches to the SRS

Yes, that's the way it worked when I was last in the box. And I believe they've added/made available FMGEC software for a TOGA to managed Nav capability for lateral nav on the missed now with SRS still the vertical mode and a switch to dual cue bars if the FPV/FPD was used on the approach prior to TOGA. So the whole Airbii CAT3 process is automated for either the auto-land or any complicated, circuitous missed track.

The original impetus for HGS was non-automated hand-flown CAT3A to either the landing or missed. So theoretically it provided all necessary capability and was to be used on the missed after that decision was made. HUD's been around on airliners since the 80s but as AFAIK a single HUD installation has never been certified as a primary flight instrument. I believe the 787 has dual HUDs so this may have changed. I'm out of the business now so take what I say with a grain of salt.

I would not presume to know if this Captain was utilizing the HGS at the time, but if he was, theoretically the whole maneuver could have been completed sucessfully on the HGS. And actually, barring malfunctions, theoretically it could have been completed successfully in a number of ways.

[JPJP]

(I don't know about 'incredibly' but certainly dynamic).....

Since FZ evidently utilize HGS at times I'll add another comment about about HGS use here in TOGA that fits with the pitch attitude 'call' discussion.

For both takeoff and go-around the HUD displays a dashed line that represents target pitch attitude for the maneuver so the raw information is already there.....however command steering (flight director 'ball') is for the FPV not the 'attitude symbol', i.e. 'boreline'), both 'ball in the FPV' and 'boreline on the dashed line' theoretically resulting in the same flight profile.

Normal phases of flight the FPV sits about 2-6 degrees below the pitch symbol. At 0.0-0.2g the FPV might end up slightly above or nearly aligned with the pitch attitude symbol. I've observed various responses to this.....
You've hit the nail on the proverbial head - The Go Around on the HUD can be a challenge for the exact reasons you've outlined. I've seen a number of people nearly stall the aircraft in initial HGS Sim training. Competent pilots with thousands of hours in the aircraft doing their Command course (no HUD on the right side, so it's their first real exposure to using the symbology. Unless theyre coming from HUD equipped military aircraft).

Some pilots prefer to look away from the HUD, and instead use the PFD for the initial pitch up during the Go Around. Especially if they're new to the HGS or ..... tired

[JPJP]

The original impetus for HGS was non-automated hand-flown CAT3A to either the landing or missed. So theoretically it provided all necessary capability and was to be used on the missed after that decision was made. HUD's been around on airliners since the 80s but as AFAIK a single HUD installation has never been certified as a primary flight instrument. I believe the 787 has dual HUDs so this may have changed. I'm out of the business now so take what I say with a grain of salt.


CAT IIIB with a single HUD installed is both approved and in use. 500 RVR for takeoff and 600 RVR (50' RA) for landing.

[Centaurus]

who came up with the excellent suggestion of flying with FDs off whenever the autopilot is in use to facilitate knowledge and monitoring of normal pitch attitudes and I think it merits serious consideration.

I agree. The only problem is you risk being flayed alive at some airlines if you dare to switch off the flight director for whatever reason. It's all recorded on the QAR. FD addiction is potentially dangerous yet you see very little about this problem in flight safety research papers

[FGD135]

FD addiction is potentially dangerous yet you see very little about this problem in flight safety research papers
FD commanding pitch up throughout the AF447 stall may well explain why the PF maintained the pitch up input on his sidestick for the entire duration!

[JPJP]

I agree. The only problem is you risk being flayed alive at some airlines if you dare to switch off the flight director for whatever reason. It's all recorded on the QAR. FD addiction is potentially dangerous yet you see very little about this problem in flight safety research papers
Amongst other things, LNAV won't arm with the FD off. Ask me how I know ...... :E

[Sciolistes]

CAT IIIB with a single HUD installed is both approved and in use. 500 RVR for takeoff and 600 RVR (50' RA) for landing.
CATIIIA HGS limits i 50'/200R.

How is it trained? What sort of material is available to flight crews to assist them?
The usual mix of propaganda, self study, sim sessions and then putting it all together on the line.

FWIW, the HGS is excellent in all conditions but I have to admit that when it comes to unusual attitude training I want to look at the PFD to confirm the attitude. The only other issue is setting an appropriate brightnss level when the backdrop is bright city lights.

The Go Around on the HUD can be a challenge for the exact reasons you've outlined.
Personally I have never seen the HGS as problematic in any regime of flight, including missed approaches, turbulent/crosswind conditions or the usual round low vis takeoffs with engine failures and windshear in the sim. Quite the opposite to be honest.

[RAT 5]

Amongst other things, LNAV won't arm with the FD off. Ask me how I know ......

But that can be fixed.

The only problem is you risk being flayed alive at some airlines if you dare to switch off the flight director for whatever reason.

That's because those air;liens never bothered to train their crews in raw piloting skills, and when some enthusiastic adventurous pilots try it on the line and make G/A's due to unstable approaches the bean counters and nervous CP's step in and ban it. As trainers we are always taught to find the root cause of a problem and start the treatment/cure there. Here he root cause is lack of skill & training. Treatment? a sticky plaster = FD + AT. Root cause still exists and is a latent ticking volcano. Every few years it spews out some ash & fumes. Once in a while it barks and shoots some dragon's fire; one day it really lets go. The same is true with minor incidents, major incidents, and a crash. The signs have been there all along.

[de facto]

Mine is not monitoring FD off otherwise their QAR would explode:D

[Jwscud]

Thanks for the notes on HUDs. What sort of display is available in unusual attitudes or upsets? I imagine they decluttering like a PFD?

I recall from my ill-spent youth playing Jane's F-15 that the attitude bars angled to point up to the horizon at extreme attitudes - is there any publicly available stuff on these presentations or is it all in FCOMs and proprietary info?

[Sciolistes]

The unusual attitude display changes completely to a central circle representing the AI. Contained within is the artificial horizon, sky pointer and pitch scale. There is a kind of truncated chevron on the ground side of the horizon that narrows to the horizon which is meant to indicate the direction to the horizon. There are symbols at +90 and -90 pitch which I can never retain an image of in my memory. The altitude and speed tapes are present. There are no flight path indicators, cues or pointers other than the sky pointer. No wind drift is shown, no tracks nor headings nor any other navigation, FMC or FMA information. The change of display would have been visible to the FZ captain as it kicks in with -20 pitch.

Wasted too many hours on Janes F15 and Longbow :\

[Duty]

Amongst other things, LNAV won't arm with the FD off. Ask me how I know ......

But that can be fixed.

The only problem is you risk being flayed alive at some airlines if you dare to switch off the flight director for whatever reason.

That's because those air;liens never bothered to train their crews in raw piloting skills, and when some enthusiastic adventurous pilots try it on the line and make G/A's due to unstable approaches the bean counters and nervous CP's step in and ban it. As trainers we are always taught to find the root cause of a problem and start the treatment/cure there. Here he root cause is lack of skill & training. Treatment? a sticky plaster = FD + AT. Root cause still exists and is a latent ticking volcano. Every few years it spews out some ash & fumes. Once in a while it barks and shoots some dragon's fire; one day it really lets go. The same is true with minor incidents, major incidents, and a crash. The signs have been there all along.

You said it...none of us should be pilots because we get to wear uniforms that say we are or can do what we're told and trained to in order to get an aircraft from A - B. Hopefully at one time you had the chance to fly because you wanted to, because it was not work, pay or a responsibility. It is exactly that which has for the most disappeared from airline flying. And so, how does one expect a pilot to truly be an aviator when it is only job and not a true skill and talent. My heart is with the families of all those that lost a loved one. It should never have happened. Stop training people to manage aircraft and put the pilots back in charge. Or keep letting this happen and blindly continue down this road. What the percentage of incidents and accident lately that are mechanical vs pilot error.

RIP

[Alice025]

It seems there was a recent letter from the Russian Ministry of Transport sent to civil aviation companies advising (not directing. advising) to include into their FFS trainings cases of 1. the loss of the spatial orientation 2. GA initiated due to windshear in the condition of the jammed elevator. Apparently, to be on the safe side while MAK continues with the search of the cause of the accident. That must be full list of the Ministry of Transport own ideas re the accident, for the time being.


It's not that they told what to do in such a case o: but themselves as a state body they, likely, feel better having "taken measures" and warned ab all things possible.

[maggot]

FD commanding pitch up throughout the AF447 stall may well explain why the PF maintained the pitch up input on his sidestick for the entire duration!

FD bars and MAN PITCH TRIM at the same time?

[PJ2]

maggot, re: FD bars and MAN PITCH TRIM at the same time? If I understand the point you're making, (mutually-exclusive circumstances), there was no "MAN PITCH TRIM"* ECAM message for AF447.

*Specifically, the ECAM message is USE MAN PITCH TRIM, (amber message when in Direct Law or loss of RA in Flare Law), or MAN PITCH TRIM ONLY, (red message should loss of both elevators occur).

[safelife]

FD state isn't a QAR/FDM criteria, at least not on the A320, at least not in any airline I ever flew. Even in China!

[PBY]

I think you are right, Safelife. Because when I flew in China, I was constantly practising FDs off and letting the copilot FDs off. And we never triggered any QARs, even though
we were aparently not supposed to fly FDs off. I always did it with the FOs I could trust and who wanted to become aviators. And even in China, there is people eager to become aviators.
As RAT5 said it. awe need to become aviators again. And it needs skill and a courage to stand up to the incompetence of the training departments. But it needs to be done, if we do not want to see more people killed. I am not saying, that people should fly FDs off if they are not comfortable with it. I am just saying that competent pilots should not be stopped by the training departments from properly training other people how to scan.
And if people in training departments are not competent enough, they should hire somebody competent, who could help them improve.
I am very encouraged by this thread to see that I am not alone who seems to think there is a HUGE problem in the airlines worldwide what concerns lack of basic flying skills.

[PBY]

And few thoughts about the HUDs display. I have no experience with it. But as an A320 guy I can confirm, that airbus stopped using a bird (flight path vector) in a goaround.
If I understand it correctly tha HUD system has the bird displayed during go around.
The major problem with that is, if we forget it clutters the display, that a bird is "performance" part of the equation "attitude +power = performance"
Soit is the same as if you flew a goaround by looking at the vertical speed as supposed to paying attention to attitude. That is the reason why bird is not good indicator when performance parameters are changing rapidly like in a go-around. Setting 15 degree pitch is on the other hand the life saving initial action (of course with power). But trying to watch a changing parameter in such a critical beginning of a go-around while not being aware of pitch can prove fatal. I don't blame the guys using a HUD that they prefer to look at unluttered AI as opposed to watching the cluttered and possibly highly enetertaining HUD display.

[737er]

What PBY said! What's amazing to me is the industry has known about this problem for 20 years and they give it lip service in manuals but then have procedures as ridiculous as making it a no-no to turn off a FD. One step forward and two steps back.

Best 25 minutes one can spend on this subject....a 20 year old video that unfortunately isn't outdated (like it should be by now):

http://youtu.be/pN41LvuSz10

[Sciolistes]

PBY,

The HGS system will display your speed deviation and current energy state based on selected thrust. It is therefore possible to instantly assess your performance (pitch vs power) at any time in any phase of flight (except UAs).

I personally find the HGS system highly intuitive (except for the UA mode) and I would be interested to know how pilots got into a mess performing manoeuvres using the HGS.

[Kulverstukas]

MAK announced that preliminary report will be published tonight.

[His dudeness]

Will that be in Russian only ?

[Samju]

Going through the above posts, the pilots of Jet Airways who made 5 perfect GAs and landed on sixth on two different airfields of South India in bad weather need to be actually commended

[striker26]

https://www.flightglobal.com/news/articles/flydubai-737-crash-probe-stabiliser-shifted-to-nose-423927/

"Russian investigators have disclosed that the horizontal stabiliser of the crashed Flydubai Boeing 737-800 transitioned to nose-down pitch at a height of 900m (2,950ft) as the crew attempted a second go-around."

Preliminary report to be out by April 19, looks like they are stressing the importance of GA procedures....

[Chronus]

https://www.flightglobal.com/news/articles/flydubai-737-crash-probe-stabiliser-shifted-to-nose-423927/

"Russian investigators have disclosed that the horizontal stabiliser of the crashed Flydubai Boeing 737-800 transitioned to nose-down pitch at a height of 900m (2,950ft) as the crew attempted a second go-around."

Preliminary report to be out by April 19, looks like they are stressing the importance of GA procedures....
Not exactly a surprise.
Have a look at post no 407. That`s where I said nothing but the stab could possibly make it go from nose up to nose down, before you can say wibble.
Now remains the question who or what made it do it.

[PBY]

From what thre Russians are saying in Chronus post, it really looks that they were still on the autopilot at 3000 feet, as the trim automatically nosed down abruptly to catch the altitude. As I said in previous posts, they indicated to tower that they want to level out at level 80 and probably forgot altitude select at 900m, which is 3000 feet. Than came the surprise of violent level out, as the power was still quite high. As the autopilot had no other choice than to pitch violently down, to keep altitude, it has probably overdone a parameter in pitch and automatically disconnected itself with quite a pitch down. And "told" the pilots: "you have control". Airbus can do this trick on pilots too. And it ended up fatel even with testpilots on board. Not sure if I can find the actual accident report, but I remember we talked about this as airbus guys around 2008. We even trained how not to do a "high energy goaround"

[PJ2]

PBY, re:it really looks that they were still on the autopilot at 3000 feet, as the trim automatically nosed down abruptly to catch the altitude. Hmmm, not sure I see this scenario. Of course, the elevators pitch the aircraft over to capture altitude not the pitch trim, with the (slower) pitch-trim/horizontal stabilizer following up after, trimming out any elevator control forces, as per usual? Also, it seems to me that normally-operating autoflight systems don't do anything "violently". They capture "as certified", which would permit 'brisk' but not "violent" manoeuvres, (depends upon the meaning of 'violent', and how 'brisk' is perceived by a tired crew at night). So if it did move, how did the horizontal stab get to the position that is claimed it got to while on autopilot - that's the question.

[Capn Bloggs]

PJ2: +1. PBYs description of what could have happened doesn't sound feasible to me either. Autopilots normally don't do that sort of thing.

[PBY]

I agree with you that normally autopilots should not do that. If something unusual happens and the autopilot does not know how to deal with it, like power kept on, it will disconnect.
Either due to excessive pitch or overspeed. The question is when it disconnected. But the trim on the Boeing is aparently very fast in trimming when on autopilot. I am not a Boeing guy, but somebody here said it before. Even if the autopilot disconnected early enough, the flight directors would still guide the pilots to nose down. Similar thing happened with many goaround accidents. I still think the autopilot disconnected on them. Could anybody who has access to the Boeing sim try to set a low goaround altitude, or try to do a goaround from intermediate altitude, keep autopilot on, set toga and "sleep through it" with no action? I wonder what it will do. Airbus will pitch down and accelerate and you have to be quick in retracting flaps. I still have to find the accident where airbus test pilots got killed this way. At least that's what I remember hearing in 2008. And of course, violent, or brisk is a question of how we define the words. But at 2am, even brisk can feel violent.

[PBY]

And Airbus constantly keeps improving the automatics based on previous incident problems.
So may be Boeing is also prone to something like unexpected behaviour in a mismanaged goaround.

[737er]

GS capture on a 737 with a wonky GS signal can result in a violent pitch down. Other than that I agree with PJ2's post. I hold on to the flight controls with white knuckles after I press approach mode until the GS is captured. If you haven't experienced one of these it's an eye opener.

[ManaAdaSystem]

As the autopilot had no other choice than to pitch violently down, to keep altitude, it has probably overdone a parameter in pitch and automatically disconnected itself with quite a pitch down.

Autopilot (A/P) Disengage Light
Illuminated (red) –

steady for any of following conditions:

ALT ACQ mode inhibited during A/P go–around if stabilizer not trimmed for single A/P operation

The NG doesn't do violent level offs during go around. If it is not trimmed properly, it will fly throught the MCP altitude rather than pitch down violently.
The indication for this is a steady autopilot disengage light.
There is also a Stab Out Of Trim light to tell you if the autopilot is not trimming correctly.

A normal go around on two engines is not a full thrust event. Nothing violent about it.

A wonky GS signal will do things to any aircraft.

[FullWings]

It’s a bit of a teaser as the status of the things that are most pertinent, AP in/out and AT in/out, are not given in the update. They must know by now but are not releasing that information.

Given that they say there were no system failures, the scenarios I can think of right now are:

a) AP out - somehow they flew it into the ground, be it from an illusion of some kind and/or trimming so far forward it wasn’t recoverable.

b) AP in & AT out - acquires, then speeds up, AP applying more and more nose down trim until it disconnects or is disconnected.

Option b) would still leave the aircraft wanting to pitch up, as the trim runs reactively, unless the power was taken off suddenly as a reaction to a possible flap overspeed. Would that be controllable using the elevator alone? Not sure but my instinct says yes.

Option a) seems more likely but why was it so different from the first GA? What happened at 3,000’ that caused such a divergence? A bunt to follow the flight director if it acquired 3,000’ followed by a loss-of-control? Can’t think of much else... :confused:

[AerocatS2A]

Can icing cause "wonky GS signal"? Sorry, if question seems inappropriate.
Not inappropriate, just irrelevant. The GS capture happens at the start of an approach, this accident happened after the approach had been discontinued and well in to the go-around.

[FullWings]

Can icing cause "wonky GS signal"? Sorry, if question seems inappropriate.
Possibly but the quality of the GS signal is irrelevant once you’ve gone around...

Edit: Ninja’d by Aerocat

[Frosch]

When flying the MAP manually with a relativly light B737, one easily might apply to much ND Trim in attempting to capture a low level-off altitude. Since the speed might increase rapidly one can find himself in a condition with Stab Trim at 0 / Full ND and T/L retarding to more or less idle.

What may come next is what the second video shows in its late stages. My company had a very very close shave with a 735 years ago going around, they lost more than 1500ft after the initial level off and were pulling as hard as they could....

It might be difficult to realize the condition one is in and the existing setting. And more difficult to make the next step and increase thrust to get rid of the impressive nose-down moment while retrimming and - probably most of it - being puzzled.

Add adverse weather and gusty conditions.

In any case interresting to see all the speculations above showing a total lack of 737-knowledge, not speaking of experience. Let's all hope those don't come from pilots.

And let's hope none of us ever gets caught flat-footed like this. It's always waiting just around the corner....

[Deep and fast]

Finger trouble on the missed, armed approach and picked up a false glide?

Don't fly 73 so disregard if talking tosh.

[mommaklee]

Quick... well, hopefully quick... question from a SLF: would a light-side 737-800 making a high energy go-around into an increasing headwind (35 -> 52 kts) be prone to a negative [longitudinal] dynamic stability state?

[framer]

With respect, all you non-pilot guys are over thinking it.
Light plane, Manual thrust,increasing headwind, 4am in the morning, haven't gotten up for a pee in six hours, crappy rosters for months on end, trim a bit too much nose down when the somotogravic hits....... that's it IMHO.
And that's why you want a well rested crew.
People in normal jobs have moments when their brain doesn't process information well often, and nothing happens. People driving cars have moments when their brain doesn't process information well and most of the time they get away with it, sometimes they crash, rarely is it headline news.
We know this crew was capable of flying a go around because they did one two hours earlier. When this comes back that there was no aircraft malfunction I hope we all acknowledge that being well rested and in good mental shape is critical to flight safety and crew rostering should be regulated to ensure that profits don't get in the way of the paying passengers expectation that they will survive the flight.

[thf]

As the crew were proceeding with another manual approach, they decided to go around again at a height of 220 meters (4 km before the runway) and initiated climb setting the engine to takeoff thrust. At a height of 900 m there was a simultaneous control column nose down input and stabilizer 5-degree nose down deflection, resulting in abrupt descent with negative vertical acceleration of -1g. The following crew actions to recover did not allow to avoid an impact with the ground. The impact occurred with a speed of over 600 km/h over 50 degrees nose down.

More on MAK website (in English) (http://mak-iac.org/en/rassledovaniya/boeing-737-800-a6-fdn-19-03-2016#115136)

[PJ2]

Frosch, re:When flying the MAP manually with a relativly light B737, one easily might apply to much ND Trim in attempting to capture a low level-off altitude. The reason that too much trim can easily be applied is because leveling-off using the horizontal stabilizer is most certainly not the way to fly any aircraft. The horizontal stabilizer is a very powerful flight control, to be used carefully and appropriately in manual flight. "Trimming-into" a level off, while not unheard of, is not the way to level off. I am well aware that it can be and has been done on the Boeing and perhaps understand why some crews may decide to operate the aircraft this way. However, the autopilot isn't going to anticipate a level off and begin trimming prior to capture.

The challenge of a low-altitude level-off on a go-around is and always has been a challenge because things are happening very fast. You have to be right on top of the airplane's performance, no matter what type you're flying; there's no magic in it - it's just part of the kit. Trimming "into" the level off is a recipe for loss of control.

PBY, others have provided some examples which may or may not be comparable to what happened here. Are you thinking of the Sochi (Armavia) or the Perpignan (XL Airways/Air New Zealand) accident? If so, here are links to the Perpignan report (http://www.pprune.org/When flying the MAP manually with a relativly light B737, one easily might apply to much ND Trim in attempting to capture a low level-off altitude.) and the Sochi Report (https://www.bea.aero/docspa/2006/ek-9060502/pdf/ek-9060502.pdf).

[Capn Bloggs]

I doubt B is plausible. The autopilot will only trim if the elevator is holding a force. It won't matter how fast the aeroplane is going, the AP will keep itself in trim. I doubt the 737 could accelerate so fast that the AP trim couldn't keep up. If the power comes off suddenly, the aeroplane will be in-trim for that speed, apart from the thrust couple. I wouldn't have thought that that would be so much that a bit of backstick wouldn't correct it; maybe a shallow descent but not a major dive.

Have a read of the Icelandair 757 GA incident at Oslo in 2002. Massive push-forward on stick to -49° and 250KIAS by the captain. Why would he do that? Illusions?

[GNS APPROACH]

Conditions:
Night in clouds, no visible horizon
Low weight with Aft CG
Low speed on final will cause more nose up trim
Manual Go Around with full thrust plus aft trim will lead to an extreme nose up attitude

Pilot will be surprised by the high pitch attitde. 20-25 nose up
high force to put the stick forward will not decrease the pitch attitude
Autopilot ON will not help the situation, except you remember to increase the speed
impossible to achieve a low level off
Nose down stabilizer will help....if you do not apply too much stabilizer, which will cause a dive

another solution:
reduce thrust
bank to get the nose down to the horizon
complete the recovery
There is also a good chance you end up in a dive

[striker26]

This might be a really stupid idea, but what if he had his thumb on the STAB TRIM button as he initiated the GA? Maybe over compensated or even lost the sensation of pressure due to tiredness, controlling the a/c in the weather? Sorry if its a dumb thought but just throwing it up there

[Airbubba]

When flying the MAP manually with a relativly light B737, one easily might apply to much ND Trim in attempting to capture a low level-off altitude. Since the speed might increase rapidly one can find himself in a condition with Stab Trim at 0 / Full ND and T/L retarding to more or less idle.


Yep, possibly confusion over whether the published missed approach altitude of 600 meters QFE still applies after an apparent verbal clearance to FL 80 on the missed approach. The 600 meters constraint is probably still in the in the FMC from earlier discussions on this thread with maybe 8000 in the altitude window. They zoom upward on the miss toward FL 80 but the flight directors and possibly autothrottles still see the lower altitude and give cues to descend. At 900 meters the PF thinks he is 1000 feet above the proper altitude and does the -1 g pushover.

Here's a similar scenario with a Korean Mad Dog freighter out of SHA in 1999:

After takeoff the first officer contacted Shanghai Departure and received clearance to climb to 1500 metres (4900 feet): "Korean Air six three one six now turn left direct to November Hotel Whiskey climb and maintain one thousand five hundred meters."

When the aircraft climbed to 4500 feet in the corridor, the captain, after receiving two wrong affirmative answers from the first officer that the required altitude should be 1500 feet, thought that the aircraft was 3000 feet too high. The captain then pushed the control column abruptly and roughly forward causing the MD-11 to enter a rapid descent.

Both crew members tried to recover from the dive, but were unable. The airplane crashed into an industrial development zone 10 kilometers (6 miles) southwest of Hongqiao airport. The plane plunged to the ground, plowing into housing for migrant workers and exploded.


ASN Aircraft accident McDonnell Douglas MD-11F HL7373 Shanghai-Hongqiao Airport (SHA) (http://aviation-safety.net/database/record.php?id=19990415-0)

[PBY]

PJ2 I found something about the Go Arounds:
It is study on Airplane state awareness during a go around.
It lists many accidents, including the ones you mention.

http://caa.gov.il/index.php?option=com_docman&view=download&category_slug=2015-10-13-06-38-50-2&alias=3437-asaga-study&Itemid=669&lang=he

[Duty]

It's not rocket science! Fly a GA like a normal take off, TO/GA, accelerate, rotate 2/3' per second and look for 15' pitch. Positive rate..... problem is that you actually have to fly the airplane.

[vovachan]

From today's MAK update

In the process of the second approach, carried out in manual mode, the crew at an altitude of 220 m (4 km from the runway) decided to "go-around" and initiated a climb with the engines in takeoff mode. At an altitude of 900 meters the crew pushed the yoke forward and the stabilizer was put 5 degrees into dive, causing the plane to go into a vigorous descent with the vertical acceleration up to to -1 g. Subsequent actions by the crew did not prevent a collision with the ground. The collision occurred at speeds exceeding 600 km / h with a pitch angle to dive more than 50 deg.

[Rananim]

If a windshear GA,then they would not change config.Once they get that positive shear back,their IAS will increase by a huge amount,and now they have flap overspeed(flaps still at 30),so FD commands increasing ANU.Pilot follows FD religiously at first.Red overspeed bar reinforces this need.This could be 30-40 deg ANU.This sets the trap.
Was he flying HUD or PFD/FD?We've already had it confirmed from HUD pilots that they revert to PFD often.We need more input from HUD pilots.

[Sciolistes]

Except that the FR24 flight profile seems to suggest a normal and consistent go around under control with the expected acceleration phase and normal missed approach and acceleration speeds until the sudden and extreme nose over.

[PJ2]

PBY, yes thanks, have seen the study, and had passed it on to some carriers.

Flight data analysis shows that the go-around manoeuvre is generally performed safely enough but not always precisely.

This is in terms of:

- pitch attitude achieved vice required,
- timely configuration changes, (flaps retracted to g/a setting, gear up) and,
- precise altitude capturing and route tracking.

Overall, power set for the g/a, and speed control do not seem to be a problem.

Often, (from sim experiences), handling & performance of the g/a manoeuvre can get side-lined and stopped mid-stream if the PM/PNF does not make the "positive climb/rate" call in a timely manner, (or omits it entirely). Inevitably this leaves the gear down until someone wonders about the noise and power settings...

In terms of cockpit management, prioritizing actions sometimes gets lost amidst the important but definitely-secondary nav and communications requirements. Flying the airplane is the first (and only) short-term requirement, (first ten seconds, say), and when things are well in hand ensuring navigation is being done.

Some will disagree with this view because you can't just fly straight ahead to 3000ft and airspace must be respected. Ideally these are done almost simultaneously but the first priority is still full control of the airplane.

I say this because go-arounds that result in an accident result almost exclusively from a loss of S.A/loss of control, (vise CFIT, mid-air collision, mechanical/technical failure, encounters with serious weather phenomenon, etc.)

I realize that some g/a required routings, altitudes and perhaps speeds are complex due to the proximity of terrain or other airports and their airspace requirements. But full control of the aircraft is primary.

[DOVES]

"SUDDEN AND EXTREME NOSE OVER"
Are the keywords!
Very strange!

[Chronus]

More on MAK website (in English) (http://mak-iac.org/en/rassledovaniya/boeing-737-800-a6-fdn-19-03-2016#115136)
"At a height of 900 m there was a simultaneous control column nose down input and stabilizer 5-degree nose down deflection.."
The control column nose down is a PF commanded input. It is the STS that is of particular interest in this scenario where the aircraft was on manual, ie a/p disengaged. STS most frequently operates on t/o, climb and go around.
The puzzling of the STS against the background of the investigators announcement that no systems faults have been found, is the word "simultaneous". Namely that both commanded input and stab deflection occurred at the same time. Cannot quite see how both could have been achieved simultaneously.

[silvertate]

At an altitude of 900 meters the crew pushed the yoke forward and the stabilizer was put 5 degrees into dive, causing the plane to go into a vigorous descent with the vertical acceleration up to to -1 g.


The answer may lie in that statement. They pulled negative, and I have seen many strange reactions to negative, especially as many new generation pilots may never have done aeros. On one occasion turbulence on approach caused a momentary 0g, and the f/o let go of the controls, screamed, and grabbed the ceiling. Bit of a worry. On another occasion in training a short 0g was confused with a stall, resulting is a substantial push forwards to 'unstall' the aircraft, resulting in -1 or more.

In this case the input of 5 units of trim is not normal. That is a lot of trim, even if the flaps are down (works at 3x speed). There is no reason to use trim like that if pitching forwards, as the cc is rarely that heavy that you need to unload simultaneously while pitching. Someone should see how long it takes to run five degrees, with the flaps down (no longer on 737). There are elements here pointing towards a sudden pitch to catch an altitude, that developed into a new unusual experience -- a 0g float -- that provoked a wrong reaction.

[Capn Bloggs]

Namely that both commanded input and stab deflection occurred at the same time. Cannot quite see how both could have been achieved simultaneously.
If there is a lot of forward force required on the control column it is a "natural" reaction to use the trim to help.

[Sciolistes]

What is 5 degrees of trim? Trim is expressed in units not degrees.

[portmanteau]

according to 737flightsim.com total stab travel is - 0.2 to +16.9 trim units and 1 degree of stab travel = 1 trim unit. Full scale travel thus = 17.1 units or degrees. Stab is neutral at 4 trim units.

[RAT 5]

Looking at this more from a human factors than technical: people speculate on disorientation, mis-reading a HUD, and other factors in the execution of the GA. I have no answers to my questions, I admit. They had performed the same manoeuvre 2hrs earlier and from a similar very safe height; thus no rush, no panic, no surprises. So why does it go horribly wrong? It is said they achieved -1g. Anyone will feel that, it is not a gentle force. You will feel something is not correct; you should understand what is causing it and the PFD will confirm it and tell you what needs to be done about it.
Summary:
- this was a repeat of a previous successful manoeuvre.
- it was at a safe height, no rush, no surprise, no panic.
- -1g is an unmissable force
- PFD showing attitude in the brown is unequivocal.

Curious.

I'm curious & disturbed to hear some guys use trim to help level off. Agh! I'm assuming they give a nose down input, slightly. They reduce attitude to level off, reduce thrust to maintain speed and the nose attitude reduces further due to the power/pitch couple. To apply some nose down trim when a few seconds later you are likely to apply the very opposite due to thrust reduction seems to be an odd technique and not one I would encourage. It is flying pitch on trim and not elevator. This is normally considered a No No. Have I misunderstood?

[Sciolistes]

according to 737flightsim.com total stab travel is - 0.2 to +16.9 trim units and 1 degree of stab travel = 1 trim unit. Full scale travel thus = 17.1 units or degrees. Stab is neutral at 4 trim units.
OK, so the flight simmers reckon that 1 unit = 1 degree. Hmmm.

Just running with that, how is it possible to get -5 units of trim then? Did they mean the crew changed the trim by 5 units nose down? I guess that must be it.

So, if the flaps were up, which the FR24 speed profile certainly suggests, then I doubt they would go from typical approach trim values with F30 (say about 7 units) to something 5 units less because the trimmer will stop at just short of 4 units. They would have had to pull the handle and trim manually.

If the flaps were still extended, then they could trim to a little more than 0 units.

In either case, with zero trim with the flaps extended or 4 units of trim with the flaps up, a level attitude still could be still be maintained with effort. It is difficult for me to understand how such a trim value could lead to such an extreme event that would result in an average of 45 degrees nose down pitch and 320kts. With 4 units of trim, flaps up and 320kts and no pressure on the control column, the aircraft would surely not be in such an extreme attitude.

[ManaAdaSystem]

http://https://www.rt.com/news/338898-flydubai-crash-records-nosedive/ (https://www.rt.com/news/338898-flydubai-crash-records-nosedive/)

If this is correct, we are looking at a completely disorientated crew, or possibly a pilot incapacitation that was not detected fast enough.
Both had pregnant wifes, so I don't think this was a deliberate action.

[liider]

https://www.youtube.com/watch?v=mPhOChy4bQs

Trying to reconstruct in a simulator

[Chronus]

If there is a lot of forward force required on the control column it is a "natural" reaction to use the trim to help.
The operative word is "simultaneous". This means both forward push on control column and nose down trim occurred together at the same time. Given manual command of the control column I cannot see how manual pitch trim could have been applied at the same time. This therefore only leaves the STS to automatically follow the manual control column command.

[Old King Coal]

For what it's worth, I happened to find myself in the (B738) sim today and therein, with some time to spare at the end of the session, I endeavoured to reproduce one likely go-around scenario which that crew might have encountered,... and let's just say that my (fairly benign) experiment ended up with the sim entering a steep dive (>40º nose down), with the speed increasing rapidly (even with the thrust levers closed, nudging 270 Kts when we hit the ground), and all the while I had the control column buried hard back in to my (admittedly a fairly expanded) waistline whilst trying to get the nose to come up, and during which I was pulling as hard as I could on the yoke, with both arms (and I'm not exactly weak), but which didn't work (i.e. the nose would not come up, even with full aft control column)... the resultant outcome of which was that we speared into the ground in an almost uncannily similar manner. It was certainly sobering stuff, and, yes, there were a couple of things I maybe could have done to get the nose-up (but, for the sake of the experiment, I didn't... veritably trying to emulate a possibly overwhelmed and tired / fatigued crew). In summary, the B737 can be a real handful in a go-around and, imho & experience, the two engine go-around has typically been badly taught & executed in every airline that I've ever been in (and I've been in more than a few!)... and I'd go so far as to say that the 2x engined go-around on the B737 is typically the most f'ked-up manoeuvre of all possible manoeuvres; though it shouldn't be, but it often is!

[PJ2]

OKC, sobering indeed, how'd you do it? Can you specify the control and engine settings that produced the dive and absence of response to elevator input? What was the stab setting just prior to the uncontrolled descent?

I've seen numerous g/a's in flight data and they're all safely flown. I'm sure many are interested in how you obtained this outcome. Thanks! PJ2

[RedBullGaveMeWings]

https://www.youtube.com/watch?v=mPhOChy4bQs

Trying to reconstruct in a simulator
This was a bit scary to watch.

[Old King Coal]

Sorry PJ2 (and others) but imho it would not be fair to the official enquiry to reveal what it was that I did to cause / set-up the sim to crash, but, suffice to say, that I found it quite easy to produce a set of (seemingly innocuous) control, power, and trim inputs that would lead to the outcome that I experienced; and any sufficiently experienced B737 pilot could probably easily replicate the same, with a little imagination.

[PJ2]

Hi OKC - understand, thanks. Will standby the investigation as it unfolds. Cheers

[Sciolistes]

So, with as much nose down trim as it is possible muster and full control column forward to induce the nose over, the speed builds to a speed that the elevator becomes insufficient to overcome the stabilizer. Either that or the tail becomes effectively stalled and is unable to produce sufficient downforce...? Control is not possible until the sufficient nose up trim has been applied.

[737er]

If sim recreation is correct...3100 in MCP, trying to level off with thrust initally at TOGA...so following FD to level off at incorrect MCP requiring applying lots of down stab trim. Then AT pulls the thrust off putting the aircraft in an extreme out of trim condition.

Hand flying with AT on combined with mode confusion. Very plausible.

[chuks]

"I was pulling as hard as I could on the yolk .... " Old King Coal telling about what happened during a sim session.

This man does not know that it is called a yoke, not a yolk?

Too, he says that the control column was fully back, "the control column [was] buried hard back in to [his] waistline" while he "was pulling as hard as [he] could on the yolk [sic], with both arms .... "

If he had the control column fully back, why should he need to pull as hard as he could, given that it's not going to move past the full aft position? It has hit the travel stop, so no need to keep pulling any harder than necessary to keep it there.

I can understand that mistrimming full nose-down might make it impossible to move the control column fully aft, but that would not be the case here; the control column is reported to have been fully aft. Why, then, should the aircraft not respond to full up elevator when it would not seem to be stalled, given the report of rapidly increasing airspeed?

Three things that do not fit: This description does not fit the way that an aircraft should normally behave; the description of the action of pulling extremely hard on a control column on the aft stop does not make sense as written; who can go through training and not know that it's "yoke," not "yolk"?

[Jwscud]

Autocorrect is the cause of many sins.

If the stabiliser is out of trim, combined with the force effect of reducing thrust, it might easily be possible to run out of elevator authority.

The MAK report makes clear that the approach was flown manually, which suggests AT off as well given Boeing guidance.

Do Flydubai use the AT ARM mode when flying manually?

Fundamentally, without seeing CVR/FDR data we are all speculating. However, as a 738 driver, I am learning things about my aircraft and thinking a lot about my flying technique. This accident is pretty much a daily subject of conversation in the flight deck.

[Sciolistes]

chuks,

OKC is a pilot par excellence. Contain your enthusiasm of minor and irrelevant errors.

[enola-gay]

In the final seconds of the SIM video, the aircraft banks over by 90 degrees prior to impact, just like the crash videos shown earlier in this thread, as it emerges from the cloud base.

Some commentors have said that such a bank angle is not possible with an extreme nose down pitch, or that it would result in a turn away from the runway, or that it would be a level CFIT anyway, despite visual evidence to the contrary.

It seems to me that the SIM has exactly replicated the event as recorded on CCTV, so why is that? And if so there ought to be a lesson for all.

[sinusake]

Totally agree with sciolistes, OKC one of the best pilot I've ever met.

[ManaAdaSystem]

The bank in the simulator video starts when the pilots turn the control wheel to the right.
Are they replicating the exact flight recorder findings, or are they flying the simulator the way it appeared to have happened?
Big difference.

[Mikehotel152]

Why, then, should the aircraft not respond to full up elevator when it would not seem to be stalled, given the report of rapidly increasing airspeed?

The position of the stabiliser is far more important than the position of the egg yolk...

[737er]

The bank could have been a lizard brain reaction to "turning away" from a ground impact.

[737er]

chuks...you are running with several misconceptions.

The stab trim moves the entire horizontal stabilizer. The elevator is about a tenth the surface area. Therefore the tail can be "flying up" with the elevator deflected fully up.

Also, probably not pertinent in this case but airspeed has a indirect effect on a stall. A wing can be stalled at any airspeed. One can also accelerate a stall on a wing or tail by having enough surface deflections to disrupt airflow such as when a stabilizer is deflected in the opposite direction of the elevator.

[AtomKraft]

There are pilots around today who know how to work an aircraft, but they don't know how the aircraft works.

The whole issue of "Trimmable Horizontal Stabilisors" is a perfect example of this.

If you have managed to move the THS from where it needs to be, to somewhere else- you have entered a world of ****, and will remain there until you have recovered the situation by putting the THS back to a more appropriate position.

The THS is big. The elevators, not so much.

THS set for "big nose down?" You can pull as hard as hard as you like on the thing that moves the elevators, and you might even recover, but you'll be hauling back until that THS is in its rightful position.

THS set for "big nose up?" Houses will initially get smaller, but not for long.

That powerful THS is what gives our aircraft the ability to be safely trimmed for take off with all sorts of different loads.

Get it out of position in flight and the best you can hope for is paperwork and awkward interviews.

[chuks]

Just questions, not necessarily misconceptions, because that narrative raises more question than it answers.

For me it starts with this "yolk/yoke" business, which I have encountered previously. It's a red flag, although it might also be something of no real significance. After all, "On the internet, nobody knows you are a dog."

I understand how the pitch trim works by moving the stabilizer, thank you. It was one of the first things they taught me, along with that that thing you yank on is called the "control yoke." In this scenario, though, the trim is grossly out, set for (full?) "nose-down," yet the PF is able to pull full "nose-up" against it, when the aircraft does not respond to that because of the trim being set nose-down. That implies that the trim had to be rapidly re-set, what, full nose-down during the go-around? Who does that, and why? Too, you are pulling with all your might against the pitch trim, without bothering to operate the pitch trim switch which is right there on the yoke? That should be reflex, I would think.

I guess we would need to be told how OKC "found it quite easy to produce a set of (seemingly innocuous) control, power, and trim inputs that would lead to the outcome that [he] experienced," such that "any sufficiently experienced B737 pilot could probably easily replicate the same, with a little imagination."

In other words, a go-around results in a fatal impact at a 40º nose-down angle with increasing airspeed at zero thrust because of control, power and trim inputs. That's a pretty alarming scenario because I can not imagine what those "inputs" from a "sufficiently experienced B737 pilot" might be. I think we need to be told a bit more about that, because this seems to be a very implausible narrative, just on the face of it.

Strange things do happen; there have been other crashes that require reading the final report to understand how they could have happened, when that was because of very strange control inputs on the part of the crew. (That Colgan crash near Buffalo is probably the worst example of that, when even the accident investigators had no real answer to why the crew flew the airplane as they did, when their strange control inputs caused the crash.) Here we have an equally strange scenario being presented in a veiled manner, out of fairness to the official inquiry (?). Okay, if you say so!

Another thing: I doubt that professional accident investigators pay very much attention to posts made here, but non-pilot members of the public, and some reporters too, probably do read these posts.

I just watched that clip from the sim reenactment, linked above and mentioned below, and found it completely uninformative. We need to be able to read the instruments, see the pitch trim settings, and see the PF control inputs in order to understand what we are being shown there, other than "a crash." What is the point of making such a video as that one?

[gulliBell]

This was a bit scary to watch.
Is it typical for pilots to move the controls (as evident in the simulator video) this vigorously in all sorts of directions when manually flying? Coming from the helicopter world, where small deliberate control inputs are the norm, the erratic nature of the controls movement in that sim flying comes as a complete surprise.

[AerocatS2A]

Chuks, you're doing a pretty good job of misreading OKC's post.

1. Yoke/yolk. Could be a typo, could be an auto-correct problem, could be that he really didn't know the spelling is different. You know that many pilots aren't the most educated bunch don't you?

2. He is not saying that any experienced 737 pilot could get themselves into the situation he described, he's saying that they could figure the situation out easily enough so he doesn't need to spell out the details of what he did. Presumably he used nose-down trim to help with an aggressive level out (light weight, low level, high power) with full power and then pulled the power back to keep the speed under control resulting in a grossly out of trim aircraft.

3. He also said that he deliberately did not trim to fix the problem because he was trying to replicate the mistake a tired crew may have made.

4. I agree that the concept of not saying exactly what he did so as not to compromise the investigation is just bizarre. But you know what? I know pilots who believe the moon landings were faked. The odd bizarre idea someone has does not necessarily negate the thrust of what they're saying.

[PBY]

Chucks, I was reading your comment where you ask, who trims down during goaround and why.
You have to realize, that the power has a huge influence on pitch.
I think what happened is quite simple. They added a lot of power during the goaround. It is normal and expected. Than the nose goes up a lot during the power application. So you have to push a lot to keep the nose at 15 degrees or to get it down to this 15 degrees, in case you slept through it. Next think you are leveling out very rapidly, because you had set up your goaround altitude low or started the goaround from an intermediate altitude. Than you need to power back a lot. You are trimmed for nose down due to trying to keep the pitch at 15 with a lot of power and all of a sudden your nose dips down due to power coming rapidly off in order to level out. Add to it the chronique inability of airline pilots to scan instruments coupled with tiredness, somatographic illusion and being behind the aircraft due to a lack of training as was mentioned in previous post.
I think we will see many of such accidents in the future. With the lack of training airline pilots are becoming like a sheep with no survival instincts. They cannot think one step ahead of the aircraft. Everything is a surprise to them.
And doing the 2 previous goarounds fine, while on autopilot and the last one badly because of manual flying... what is so difficult to understand it went wrong? High energy goaround keeps killing pilots with lack of instrument scanning ability, period.

[chuks]

I am not misreading anything, just asking logical follow-on questions.

For one thing, the pitch trim switches are placed right there on the yoke, when it's logical that someone who has just trimmed down-down-down is now going to trim up-up-up. That's not quite the right way to fly the aircraft, no, but that's what someone might do who's over-using the trim; he's now going to use the same thing to get himself out of the mess that he had previously used to get himself into that mess.

It's completely unrealistic for OKC to tell us of a scenario where he is pulling with all his might against the trim without bothering to re-trim using switches that are right there on the yoke. Who would do that, especially given that they would have been using those same switches shortly before to re-trim the aircraft? It is not as if the PF is going to suddenly forget to use the same secondary flight control, pitch trim, that he already had been using, is it? This is not, at first glance, a realistic scenario, so that we need to be told more about how it's supposed to have come about.

Yes, you could set up your aircraft to crash by trimming full nose-down on a go-around at low altitude while also going to idle thrust, but then the first question would seem to be, why not simply correct those settings?

[FGD135]

For all those scratching their heads about how OKC - and the YouTube video - got the aircraft into that nose down attitude, where even full back stick was ineffective:

Have another look at that YouTube video. Make sure you have the sound on. There is a certain sound that starts at 0:39 and only ceases at 0:50.

That sound explains everything - and could very likely be exactly what also happened on FZ981. If you don't know the significance of it, you probably should be doing a little less posting and a little more reading.

The way I read this video (it is very blurry so it is only my best guess) - he is overpowering the autopilot making it disconnect ... which ends with a stall There was no stall. The autopilot disconnects upon TOGA - when single channel - which is SOP for FlyDubai. This has been brought up many times in this thread.

For me it starts with this "yolk/yoke" businessFFS, chuks, forget how the poster spells that word. He is referring to the control column. With enough AND trim, you can pull the CC to its rear stop with no apparent effect on the flight path. You should know this.

Too, you are pulling with all your might against the pitch trim, without bothering to operate the pitch trim switch which is right there on the yoke? That should be reflex, I would think.
Something you don't appear to appreciate about human behaviour, chuks, is that when under extreme stress, humans don't necessarily respond the way they would when calm.

AtomKraft, excellent post!

[olasek]

The autopilot disconnects upon TOGA - when single channel
Except - as we know in this case - the approach was flown manually so how in the hell autopilot disconnected if it was never connected in the first place? Perhaps this video has little to do with actual events that transpired.

[Microburst2002]

If the crash cause is a wrong THS setting and subsequent incorrect reaction to its effect (elevator only withount readjusting the THS) then they must include fatigue as the main cause of the disaster, as it is the only thing that explains such a succession of mistakes in a pair of otherwise competent pilots.

[FGD135]

A few posters here seem perplexed at how a pilot wouldn't "instinctively", or "reflexively" reverse his pitch trim inputs after the aircraft rapidly entered the dive.

These posters perhaps don't understand human behaviour very well. Put a human under enough stress, and they won't make the same responses they would have when calm.

Here is an example. In 2004, a pilot of an Aerocommander AC500S engaged the autopilot shortly after reaching top of climb. Unfortunately, the design of the human/machine interface in the case of this autopilot was very poor.

The autopilot immediately pitched nose down, and proceeded to wind on full (or near full) nose-down trim. The aircraft, in a steep dive, exceeded limit airspeeds and disintegrated in flight.

ATSB investigation report here: https://www.atsb.gov.au/media/24274/aair200400610_001.pdf

It appears that the pilot was startled by the immediate and violent pitch down, and responded by pulling on the CC - rather than by disengaging the autopilot.

[AerocatS2A]

Add to it the chronique inability of airline pilots to scan instruments coupled with tiredness, somatographic illusion and being behind the aircraft due to a lack of training as was mentioned in previous post.
I think we will see many of such accidents in the future. With the lack of training airline pilots are becoming like a sheep with no survival instincts. They cannot think one step ahead of the aircraft. Everything is a surprise to them.
And doing the 2 previous goarounds fine, while on autopilot and the last one badly because of manual flying... what is so difficult to understand it went wrong? High energy goaround keeps killing pilots with lack of instrument scanning ability, period.

Me thinks you are overstating the limitations of airline pilots somewhat. Crashes are still very rare, much more rare than they used to be.

[Kulverstukas]

This posted video was made by Chief Pilot inspector of S7/Globus Denis Okan. He was specially tried to repeat accident condition. He has large post in his LJ with throughout explanation about this simulation.

Accident scenario - -= Fly Safe! =- (http://denokan.livejournal.com/143802.html)

[Sciolistes]

Chuks said:
Strange things do happen; there have been other crashes that require reading the final report to understand how they could have happened, when that was because of very strange control inputs on the part of the crew. (That Colgan crash near Buffalo is probably the worst example of that, when even the accident investigators had no real answer to why the crew flew the airplane as they did, when their strange control inputs caused the crash.) Here we have an equally strange scenario being presented in a veiled manner, out of fairness to the official inquiry (?). Okay, if you say so!
However, this I agree with 100% This is a concern of mine in this event.

Chukss also said:
It's completely unrealistic for OKC to tell us of a scenario where he is pulling with all his might against the trim without bothering to re-trim using switches that are right there on the yoke. Who would do that, especially given that they would have been using those same switches shortly before to re-trim the aircraft? It is not as if the PF is going to suddenly forget to use the same secondary flight control, pitch trim, that he already had been using, is it? This is not, at first glance, a realistic scenario, so that we need to be told more about how it's supposed to have come about.
If you look at my posts, I am with the notion that a crew who already performed a go-around and were expecting to make another go-around and then flew what appears to be a stable second go-around with all the available parameters consistent with such, then suddenly end up diving at 13,500 FPM in 7 seconds from a 1350 FPM climb cannot possibly be explained away with just crew error.

However, I can understand how, once trimmed fully nose down, if the speed is allowed to builds sufficiently, then even full aft elevator may be enough to recover the aircraft. With 4 units of trim, I could never have imagined it but I can accept it. With zero units and the flaps ripped of I can easily believe it.

But, what is most puzzling is why the half way down the descent, the flight path steepened still further. Any attempt to pull back on the stick would have resulted in, at worst, a pitch up, however slight and whatever the trim. Perhaps there is a point at which the elevator becomes stalled and looses all effectiveness?

But as Chuks ponders, if there was nothing wrong with the aircraft, why not simply trim nose up. It is inconceivable how this was not the first and initial reaction of even the most fatigued, surprised, shock, scared and startled crew member, never mind crew members!




BTW, any bank angle can easily be explained away. At high speed, even the slightest and gentlest input will result in an instant response and roll - even with no intention to bank the aircraft it would be unlikely that a crew trying to recover won't command some roll at such speeds. The aileron feel system uses only springs and does not replicate dynamic aerodynamic loads in the same way as the elevator system.

[ManaAdaSystem]

They added a lot of power during the goaround. It is normal and expected. Than the nose goes up a lot during the power application. So you have to push a lot to keep the nose at 15 degrees or to get it down to this 15 degrees, in case you slept through it

Can we please stop repeating this rubbish?
A normal two engine go around in the NG is not a violent, lots of power event. There is no need to push a lot or trim forward go get the nose to 15 degrees. It pretty much parks there if everything works OK.
If, for whatever reason they decided to use full thrust during go around in a light NG, it could get interesting really fast.

This was a single channel automatic approach with a manual go around. The autopilot disconnected just at it should do. FZ SOP.

OKC is a very experienced pilot. Stop making him look like an idiot because he did a typo. He made a post about trying to replicate this crash, but unless I am mistaken, the video posted is not his.


But, what is most puzzling is why the half way down the descent, the flight path steepened still further. Any attempt to pull back on the stick would have resulted in, at worst, a pitch up, however slight and whatever the trim. Perhaps there is a point at which the elevator becomes stalled and looses all effectiveness

The stabilizer is the boss. No way the elevators will bring the aircraft out of a pitch up/down if the stab is grossly out of trim.

[737er]

Mostly Agree Mana, although the 737 at full TOGA thrust, especially at light weight, does pitch up and can be a handful. That's why there are two TOGA modes with the AT engaged. A single push of the TOGA button results in pitch and power approximating a 1500 fpm climb while a two push TOGA gives full TOGA thrust. There is a reason for that feature. You sort of said that, but kind of contradicted it in your admonishment of a post as well.

Stabilizer is the boss? Spot on!

Sciolistes,

You inquire why the path steepened but really you answered your own question at the same time. As the airspeed increased the "crossover" effect of the dominant stabilizer authority probably continued to increase thus driving the nose down more and more as AS increased. Also, I don't find it inconceivable that a very fatigued crew under certain circumstances could react this way during a TOGA.

[ManaAdaSystem]

I said in a normal go around. Again, there os nothing violent about a normal go around in the NG.
A full thrust go around is not a normal procedure in a light NG.
I have said long time ago that full thrust combined with a "surprise" level off could go wrong very fast.
If you trim way forward, don't be surprised if the nose suddenly points down. It is designed to do that.

What surprised me in the video was how little time it took from level, pitch down to crash.

[Jwscud]

This was a single channel automatic approach with a manual go around. The autopilot disconnected just at it should do. FZ SOP.

The MAK intitially report referenced made clear the approach was being manually flown. What is not so clear is:

1. Was the autothrottle engaged?

2. If thrust was being managed manually was the autothrottle ARM mode used?

3. Was a normal go-around flown or was it a Windshear escape manoeuvre?

There are many unanswered questions of "what" before we get into "why"

However, as many have already suggested, fatigued people may do strange things or end up behind the aircraft. I'm sure we have all done daft things in more benign conditions and been saved by altitude, reacquiring situational awareness, or the person in the other seat.

I have also operated while fatigued (not in an aircraft and during time in the military) and the ability to make basic mistakes in that condition is quite shocking.

On a regulatory front, I hope this will at the very least bring to the end the farce that the head of the Emirati regulatory body also happens to own EK and FZ...

[Ian W]

Several studies have pointed out that fatigue (often called drowsiness) causes as many errors as being under the influence of alcohol. This should be pointed out to the roster managers in the airlines that appear to be using maximum hours limits as normal rostering hours.
If airlines will not allow their pilots to have a beer before duty, then they should show as much concern to flying tired which is now being shown to be as likely to cause errors.

Perhaps gate checks should include the crew's previous months rostering.

In this case the crew also were put into a difficult Human Factors position one that was pointed out in 1908 by Yerkes and Dodson http://pe-arousal.********.com/2011/09/inverted-u-theory.html (mentioned earlier in the thread) they went from relatively high arousal on the approach to doing a routine go around albeit for just 2 minutes no doubt relaxing back a little to the arousal/boredom of the previous 2 hours holding, then all of a sudden everything starts to go pearshaped and they are at the other end of the arousal spectrum - in HF terms that is going direct from one error prone state to another. Fatigue and over/under arousal are almost guaranteed to lead to errors.

[Skyjob]

1. Was the autothrottle engaged?
2. If thrust was being managed manually was the autothrottle ARM mode used?
3. Was a normal go-around flown or was it a Windshear escape manoeuvre?

1. Probably when AP was flying it (but may have been disconnected to allow manual thrust control as conditions may have dictated, but on TOGA for missed approach regardless would have set initial thrust, then await further instructions).
2. Once TOGA is pressed, AT move up, if AT had been disconnected prior on approach, AT will not react further unless re-armed by crew during re-engagement sequence, usually when aircraft is being levelled out in trim.
3. It does not matter in this case, unless you are attempting to establish if crew (should have) disconnected AT as part of flown procedure.

Here is a thought:

On an ACQ manoeuvre, MCP speed window opens, if a low level altitude acquire happened then speed will be actual rather then associated flap speed, thus AT when selected will be reducing power with open speed window to establish commanded speed rather then required speed.
Add to this the possible FDs commanding the lower altitude which has been bust (as not set the higher FL080 in MCP) and FDs wanting to fly downwards (pitch forward), you need not think too long about what can happen next, when ballooning trying to re-ACQ the overshot altitude.
Another problem could be a vertical mode selection on MCP by crew: if the procedure is coded to have lower level off but MCP Altitude is set correctly at FL080, when Flaps Up, an MCP selection of VNAV may result in a descend under certain conditions when selected...

[framer]

Could either of these things have happened?
1/ two taps of A/T instead of one? Yip.
2/ A whole handful of thrust if A/T not engaged? Yip.

So a simple error ( either 1 or 2) and you now have a lite NG with full power climbing into an increasing headwind at 4am with a crew who has been airborne for six hours, one of whom allegedly resigned due fatiguing rosters.
It is not difficult to imagine how the above situation is only a few moments of brain-fart away from tragedy.
So if this turns out to be the case, what should be done?
Regulate to ensure our Airline crews aren't rostered to the point of fatigue.
They should be the opposite. Mentally fit, well rested, well trained.

[Sciolistes]

737er,
Also, I don't find it inconceivable that a very fatigued crew under certain circumstances could react this way during a TOGA.
No, it is not inconceivable. But this appears to have happened at the end of a what, by profile and speed, appeared to be an adequately executed missed approach. Long after the TOGA button was pressed and after the acceleration phase was complete or near the end of that phase. So it is inconceivable that they managed to control the aircraft at the critical point and end up with such an extreme and sudden nose over when the aircraft was what appears to be, completely stable.

[Twiglet1]

Several studies have pointed out that fatigue (often called drowsiness) causes as many errors as being under the influence of alcohol. This should be pointed out to the roster managers in the airlines that appear to be using maximum hours limits as normal rostering hours.

IanW - Sleepiness. Fatigue - unable to suggest this as roster of F/O was short. He would have been peaking on this flight but that would be the case for any busy roster.
Limits - yes regretfully the world we live in these days. No use pointing at Roster Managers. NAA's, EASA, IACA etc

[silvertate]

As to the use of the trim, if you have just been using the trim switches, yielding some unpleasant result, how in the world are you suddenly going to forget all about the use of the trim switches, as in pushing them the other way from the way you just did push them? That would be a brain-fart of cosmic proportions.

Well, that's a Middle Marker tone, I think.

I think it is fairly clear that someone had their thumb on the trimmer for some considerable time during the pitch manoeuvre to catch the altitude. Why, is another matter. An incorrectly learned response? Out of fatigue? Out of fright? A mechanical malfunction? We do not know at present, but it is likely the fault lies with the trimmer.

As to the question of the 'noise' on the video, the cryptic poster was referring to the trim-wheel wizzing for quite some considerable time. This is not a noise you are likely to miss, to comment on, and to react to, if it happened of its own accord. So perhaps we can rule out mechanical failure.

ST

[Chronus]

The 738 is an aircraft designed for automatics. It has STS which basically is a speed stability
augmentation system designed to improve flight characteristics during during operations with low GW, aft CG and high thrust when a/p is not engaged. STS monitors the stab input and thrust lever positions, air speed and vertical speed and trims the stab with the a/p stab trim. The STS operates counter to pilot inputs.
Somewhere therein may lay the answer to this puzzle.

[PJ2]

The 738 is an aircraft designed for automatics. It has STS which basically is a speed stabilityTo clarify slightly, all B737 Classics & NGs have the "STS" system.

[Jwscud]

There is no "trim in motion" sound on the 737, merely the generally noticeable sound of the trim wheel spinning. The "sound that explains everything" is the 5 seconds of the trim wheel running. When I am next working I will have a look how much of the trim range 5 seconds of trim at high rate covers, but I would guess it is not far off half the total trim range.

Most who fly the 737 will subconsciously be aware of any trim movement, and look to see what caused it, especially after the Turkish accident, which I suspect almost every 737 driver has relived in the sim. In that case, the biggest clue (apart from the speed and the speed trend dropping through the floor) was the trim wheel running considerably longer than it would in any normal condition.

[Sciolistes]

Chucks,
heard earlier, but it does not run for very long. The Middle Marker tone is the only one sounding over that whole period.
The trimmer in that video was running for 12 seconds! But the video is misleading as they had not completed the flight profile that is evident in the FR24 data and the flaps were still extended - which is why it rolled so much too. Disregard.

[framer]

Limits - yes regretfully the world we live in these days. No use pointing at Roster Managers. NAA's, EASA, IACA etc
Hopefully Twiglet your take on this is not shared by the majority. If it is we will see more and more accidents of this nature as the rosters become more and more 'efficient'.

[Capn Bloggs]

The "sound that explains everything" is the 5 seconds of the trim wheel running. When I am next working I will have a look how much of the trim range 5 seconds of trim at high rate covers, but I would guess it is not far off half the total trim range.

Not a 737 but now called a "Boeing": my trim runs at 0.3°/per second. Video it with your phone... on the ground. ;) I also get a "Stabiliser Motion" call from "Patricia" if the trim runs continuously more than 1 degree.

[chuks]

As to trimming and human factors, there was a rather interesting accident in the States to a Beech 1900.

It started with a mistake made by an engineer who was working on his own on a late-night shift. He somehow reversed the way that the cable to the elevator trim was run, so that it ran in reverse back at the tail of the aircraft with the cockpit indications still showing normal sense. When he finished his task he did not check that the trim ran in the correct direction.

Next, the crew did not do a visual check of the way that the trim ran during their pre-flight walk-around.

Finally, just after take-off the PF went for nose-up trim, when the aircraft went nose-down. He continued to command nose-up until he ended up with something like 80 pounds of nose-down force on the yoke, when the aircraft then went into a terminal dive and crashed. It's interesting that at no time did the PF stop trimming, even though it should have been obvious that something was wrong with the trim system then. There was that sort of fixation on an expected outcome that has been mentioned here previously, although there was an obvious technical mistake that started that accident chain.

It will be interesting to learn what sort of interaction there was in this crash between the two flight crew, what the human factor was, since it's already been reported that the aircraft had no technical defects. If the PF had made some mistake, how did the PNF react to that, and why?

[Airgus]

FCOM 9.20.9

Speed Trim System
The speed trim system (STS) is a speed stability augmentation system designed to improve flight characteristics during operations with a low gross weight, aft center of gravity and high thrust when the autopilot is not engaged. The purpose of the STS is to return the airplane to a trimmed speed by commanding the stabilizer in a direction opposite the speed change. The STS monitors inputs of stabilizer position, thrust lever position, airspeed and vertical speed and then trims the stabilizer using the autopilot stabilizer trim. As the airplane speed increases or decreases from the trimmed speed, the stabilizer is commanded in the direction to return the airplane to the trimmed speed. This increases control column forces to force the airplane to return to the trimmed speed. As the airplane returns to the trimmed speed, the STS commanded stabilizer movement is removed.

STS operates most frequently during takeoffs, climb and go-arounds.

Conditions
for speed trim operation are listed below:
• Airspeed between 100 KIAS and Mach 0.5
• 10 seconds after takeoff
• 5 seconds following release of trim switches
• Autopilot not engaged
• Sensing of trim requirement

[olasek]

So it is inconceivable that they managed to control the aircraft at the critical point
There is no such single "critical" point, the whole go-around which ends with hold entry or whatever follows is a series of critical points, they were still close to ground, the critical phase was far from over. Also a correct execution of prior steps has absolutely no bearing what can happen next so argument that things can't go bad because they were so good before I find quite laughable, the history of aircraft accidents nixes it.

[ManaAdaSystem]

Critical points?
It's a go around. No more critical than a take off.
I've done four this winter. One from an ILS at 3500 ft, one from 2000 ft on a non precision, one from ILS minima dual channel and one from ILS minima single channel.
I was not aware I was in a critical situation on any of them. No high thrust, white knuckled, struggeling to control the pitch events.

A go around is a normal procedure. Why do some of you think this is a near disaster?
Any part of the flight can become critical if you don't know what you are doing, or if your brain is working like a bowl of syrup because you are tired.

[chuks]

It's difficult to imagine that some versions of the 737, with almost nine thousand in all having been built so far, should be as difficult to control on a go-around as it's been said to be by some posts made here.

At its simplest, doesn't a go-around merely consist of the following?

The go-around decision and the annunciation of that to the other flight crew member.

Actuation of the TOGA switch by the PF.

Display of the desired pitch attitude for go-around on the command bars of the flight display with manual pitch to the bars by the PF.

Simultaneous manual selection of TOGA power by the PF.

Identification of positive rate of climb and the subsequent command by the PF to raise the landing gear, and so-on.

As just stated, that's a fairly routine maneuver that is practiced in every recurrent training session. It's not as though there's any real element of challenge to it as such, so that the question here seems to be "What went wrong during the execution of a routine maneuver?"

There seems to be a suggestion here that the 737 might rear up on its tail, going almost out of control, during a go-around. I don't think such behavior would be tolerated by the FAA when doing certification of the aircraft, since that would, indeed, sometimes make a go-around a a real challenge.

Is that a correct assumption, that its behavior is always relatively benign, or is the 737 really that difficult to control under certain circumstances, such as light weight, max power, and CG on the aft limit?

[Sciolistes]

It's a go around. No more critical than a take off.
Which is why I never understood why the two engine go-around is such a different procedure and different systems behaviour from a take-off. Why?
It's difficult to imagine that some versions of the 737, with almost nine thousand in all having been built so far, should be as difficult to control on a go-around as it's been said to be by some posts made here.
A go-around in a 737 is about as benign as one can image. Hardly any trimming is required. The perfect go around can be bit more tricky, manually setting the correct thrust, verifying LNAV, accelerating at correct altitude, managing the capture of the altitude before flaps up/clean speed, telling ATC to shut up, finding a moment to ensure the aircraft is properly trimmed to get the A/P in, remembering the After T/O checklist in amongst the deluge of ATC vectors/queries why you go-around/endurance/etc, etc, etc.

[Aluminium shuffler]

A 737 go around is very simple. The only trap is the alt aquire MCP speed window opening while you're still accelerating, which can leave you below the manouvering speed for new flap position, so you just need to keep an eye on that and select an appropriate speed.

[RAT 5]

One problem I see is this: crews are taught to do only one GA profile. It is always practiced from DA and often - IMHO - written as a rushed manoeuvre and made worse by being very different to a normal takeoff.
ManaAdaSystem says he did an ILS GA from 3500'. That is an odd one. If that is agl, i.e. 11nm out, why not make an orbit/hold? Also it might well have been above MAA. Give that to the average trained monkey, or even from 1200', and the outcome is unpredictable. They know only one method and it doesn't fit the scenario. The a/c needs to be managed via its systems. The pilot has all the necessary tools at their disposal, but often their blinkered training hasn't included all the possibilities. Either they have not been taught or are not allowed to use them in deviation from a rigid SOP. A recipe for a screw up.
If one has correct training, good understanding and freedom to use discretion/airmanship then a GA is a benign as any takeoff. To answer why it is not you have to visit the training depts.

[framer]

My thoughts are that if the go around is done in a calm, controlled, deliberate manner, then as folks are suggesting, there is nothing at all beastly about the NG's behaviour ( or the -300's but it's been seven years since I flew those). That said, if too much thrust is applied, in an aircraft under say 58T, then quite a lot of physical effort will be needed to push forward on the control column to keep the attitude reasonable. If the pilot has been wound up enough to apply too much thrust, then there is a real likelyhood he or she will be wound up enough to wind in a fair whack of nose down trim in an effort to ease the ( maybe unexpected) forces on the control column. If they wind in too much, and then reduce the thrust......what happens?
I don't think such behavior would be tolerated by the FAA when doing certification of the aircraft, since that would, indeed, sometimes make a go-around a a real challenge.

Is that why the 737 has a speed trim system for operation at lite weights, aft c of g and high thrust situations? In order to satisfy the FAA certification requirements? Has this scenario been known for decades?

[Aluminium shuffler]

Forward column pressure on a go around was only an issue on a manual go around from below 380' on an autoland app, which is unusual (one company I worked for insisted on all ILS apps being dual channel, to land manually or auto as appropriate to that airport, which could cause an issue if the cloud was below 400', and for the MAP at busy places like LGW if traffic was slow in front of you). Otherwise, it doesn't need much pressure.

[framer]

Aluminium Shuffler, when you say it didn't need much forward pressure are you talking about a go around with a moderate thrust setting ( ie 85% or so depending on weight) ?
I ask because at lite weights, with an aft c of g and a fist-full of thrust ( ie mis-managed) a significant amount of forward pressure is required on the control column.

[Jwscud]

I agree with framer, which is why the big question for me is what level of automation (if any) was used on the go around and whether it was a Windshear escape manoeuvre.

There is a pretty big difference between a push of TOGA giving you reduced go around thrust and firewalling the thrust levers and getting more than full rate thrust from both engines!

[Sciolistes]

Looking at the data available, it doesn't look like anything other than an adequately (not perfectly) flown standard go-around! In other words, not an escape manoeuvre neither any signs of disorientation in the flight path leading to the nose over.

https://dl.dropboxusercontent.com/u/6615175/Screenshot%202016-04-11%2009.37.20.png

[RAT 5]

I joined a company that was acquiring the new NG a/c. Their GA manoeuvre/profile was carried over from their previous jet: full umph, 2 hands on control column until clean.
They then started autolands on their new toy. I pointed out that an auto GA used only +/- 88%. Thus if it was OK for a low level autopilot GA, when the a/c made its own mind up, why not copy it, manually, from a higher height and higher workload? After years of deliberation it was agreed it was not wrong and could be taught, but it was another while before it was written into 'crew guidance'. Not quite an SOP, but better than nothing.

This info was gleaned from watching automatic GA's. Now FZ don't do those; so do they realise the performance possibilities executing a safe GA with less thrust? What is their SOP for thrust on a GA, especially at an unusually high height?

If indeed they expected to land and had set the normal MAA, and then made a high GA into a low level capture with high ROC it was a recipe for a stiff challenge. It would be curious to know what was different about the first GA and what was set in MAA. It would be very interesting to hear the CVR crew briefing for both approaches. Did they anticipate a GA? Did they discuss the FL80 GA on the 1st one? Did they set 8000 in MCP on the 1st, but set the much lower correct one on 2nd attempt? Did they brief/anticipate a GA on the 2nd one; and if so, what was their Plan B afterwards. Did the Capt, in fact, fly both GA's?

Time will tell, but I hope the report will include these salient points. There has to be a significant reason why the 2nd GA went so horribly wrong and not the 1st. Indeed, was the first squeaky clean?

[Old King Coal]

An interesting article, well worthy of a read:

http://www.caa.co.za/Aviation%20Medicine%20General%20Information/Disorientation.pdf

[arabian rancher]

For those who are still interested, five seconds of trim operation with the flaps up is approximately one unit of trim.


Had a play with it today in various phases of flight, after take-off (flaps up and down) and on approach (with flap 5, 15 and 30).


Didn't require any huge force to fight against it, and the F/O didn't even notice that I was doing anything at all unusual. (Before anyone says anything we were in calm conditions, good VMC and above 1000 feet, wouldn't have been messing with it near the ground with a load of passengers).


This was in the real aircraft, not a simulator. Not saying that trim didn't play a part, as to say anything with no inside knowledge would be just guessing, but hard to see how five seconds worth, or even twelve seconds worth with the flaps up, would make a dive unrecoverable.

[klintE]

For those who are still interested, five seconds of trim operation with the flaps up is approximately one unit of trim.


Yes. And following IAC statement:
"At a height of 900 m there was a simultaneous control column nose down input and stabilizer 5-degree nose down deflection, resulting in abrupt descent with negative vertical acceleration of -1g."
makes it even more bizarre.


In other words, not an escape manoeuvre neither any signs of disorientation in the flight path leading to the nose over.


Well, illusion of climbing occurs when plane isn't really climbing or not climbing as fast/steep as pilot perceives. Otherwise it wouldn't be an illusion.
Good explanation of spatial dis. in part. somatogravic illusions: Spatial Disorientation - SKYbrary Aviation Safety (http://www.skybrary.aero/index.php/Spatial_Disorientation)

[Sciolistes]

Well, illusion of climbing occurs when plane isn't really climbing or not climbing as fast/steep as pilot perceives. Otherwise it wouldn't be an illusion.
Good explanation of spatial dis. in part. somatogravic illusions: Spatial Disorientation - SKYbrary Aviation Safety

But it was climbing, climbing consistently and apparently correctly. So it would seem they were not disorientated and the aircraft was completely under control. You can even see nicely controlled acceleration phase. That is a very strange kind of illusion.

[donotdespisethesnake]

But it was climbing, climbing consistently and apparently correctly. So it would seem they were not disorientated and the aircraft was completely under control. You can even see nicely controlled acceleration phase. That is a very strange kind of illusion.

What flight profile would you expect to see if they were disoriented or suffering from a somatogravic illusion?

[chuks]

The thing about somatogravic illusion is that while it often involves an acceleration of the aircraft that acts upon the vestibular system, it can also involve a direct acceleration of that system caused by a rapid change of head position, something as simple as a quick drop of the head to look for an object in the cockpit such as a pen or a chart.

Given the fairly steady state of the aircraft prior to its rapid final descent, that might be a plausible explanation for one part of what initiated the accident sequence.

[RAT 5]

Somehow I think "can't see the wood for the trees" is becoming relevant to all the multi theory speculation.

[Teddy Robinson]

Somehow I think "can't see the wood for the trees" is becoming relevant to all the multi theory speculation.

Absolutely, it has become a feature on this website to the detriment of reasoned analysis.

[Sciolistes]

What flight profile would you expect to see if they were disoriented or suffering from a somatogravic illusion?
Something inconsistent and unlike the expected profile. Maybe something like Tarastan perhaps.

[klintE]

But it was climbing, climbing consistently and apparently correctly. So it would seem they were not disorientated and the aircraft was completely under control. You can even see nicely controlled acceleration phase. That is a very strange kind of illusion.

Every illusion is strange. For me, even more strange thing is how possibly pilot might have ignored ADI indication. I think we need one more factor to explain this (if it turns out actually truth)
And, referring to flight path you've posted, to get a better review you need to add pitch angle (and speed) change to the image.

[Sciolistes]

And, referring to flight path you've posted, to get a better review you need to add pitch angle (and speed) change to the image.
Obviously pitch angle isn't available, but the speeds would seem to be completely normal, so I would expect the pitch angle to be commensurate.

[PBY]

klintE, you are asking how a pilot could ignore ADI indication. I think that constantly flying on the autopilot, or manually flying with the FDs makes for a very efficient degradation of the ability to scan. I see it in the sim. I have to teach a lot of basic scanning techniques.
Especially those who flew only glass cockpit are very vulnerable. They have not developped
proper scanning techniques, even though they might be flying glass for years. And the skill does not get better under stress. I have seen people pushing down in the sim, which initially was a correct reaction to a nose high attitude, but keeping to push without noticing the original nose high situation was developping to nose low. I even had an FO who did not know the little dot was a pitch, as he was flying by looking only at the bird. There is people here who do not instruct. So they do not know the state of general flying ability. And they forget that there is a difference in the ability to actively scan as opposed to being a happy pilot-passenger kind of automation dependent until the skill is needed....

[PBY]

There is only one remedy to spacial disprientation. It is a good scanning technique and trusting the instruments.

[PBY]

Correction: spatial disorientation

[SLFinAZ]

I'm somewhat confused and don't want to overstep my limits here. I've got enough RW experience (152/172) to have completed my solo but not my PPL (son was diagnosed with autism).

I have no instrument experience...however...given the conditions and low cloud cover and a manual maneuver how would the PF not be flying pitch, power and artificial horizon/attitude indicator?

Is the modern flight director, HUD and other "help" such a distraction that the fundamental realities of pitch, power and attitude are that obscured?

[porterhouse]

how would the PF not be flying pitch, power and artificial horizon/attitude indicator?
Because pilots are human beings and can be easily distracted, fooled by senses, etc.
If you have some flight experience - grab some good book on aircraft accidents like for example "Aftermath" (it's written for pilots), it should open your eyes what human pilots (regardless of experience level) are capable of. I would make it a mandatory reading for any private pilot. Perhaps this would "un-confuse" you or confuse even more ...

[PBY]

SLFinAZ,
you have a correct question. I am a very current captain, who is almost religious in keeping my scanning ability current. I manually fly a lot, because I feel I must keep current because I owe it to my passengers safety. But even I get sometimes somatographic illusions. And it gets really crazy. My whole body is telling me I am in a turn, when in fact I am level. The urge is so strong, than even if I see it on the instruments that I am level, I still put the controls into the turn. But than I correct it quickly. I feel like a Rowan Atkinson in Johny English movie, when he does not want to kill the Chinese prime minister but has to fight himself not to do it.:). The movie is very funny :). But if you have never had somatographic illusions you will not believe how strong it can be. One of my experienced friends once dropped a pen on the floor during IMC and than picked it up. He had to give controls to the FO for the rest of the approach. He felt so screwed up. May be hape had a cold too, or was fatigued. But he said it felt like a violent tumble to him.
You see, I am current on instrument scan and I have to fight this illusions quite hard. And now imagine that most people are not current and cannot be under the existing airline training philosophy, which is just a philisophy and has not much to do in most cases in survival of difficult conditions. And the sim is unable to simulate somatographic illusions.
It is like you get off from marry-go-round and you try to walk straight. You see you are inclined, but you cannot correct it and you fall. But your life does not depend on it.
In flying an aircraft it it a question of life and death, so we have to find the streangth, be trained properly and be well rested. But airlines are prostitudes and the shareholders or owners are the pimps....

[PBY]

Actually there are some exceptional airlines, which are ok.

[fireflybob]

Perhaps it's worth mentioning here that with most aviation authorities you can qualify for an Instrument Rating and never have actually flown in cloud.

Flying in "real" conditions where you are flying in and out of cloud with cloud at different levels with different orientations with respect to the true horizon can be far more disorienting than flying with the screens up whilst under training.

Throw in some rain and turbulence or even wind shear with fatigue in the mix and you have more ingredients for undesired consequences.

[chuks]

You can experience somatogravic illusions in a sim just as you can in an aircraft in flight. In fact, when you think about it, a full-motion sim uses somatagravic illusions in combination with its visuals to create realistic sensations of motion.

When you let off the brakes and put up the power it's not that the sim cab goes scooting across the room; it just tips back to create a similar feeling to positive acceleration, using a shift in the direction of gravitational acceleration that goes misread because of where the visuals and the flight displays put the horizon. Step on the brakes and it tips forward to give you the feeling of negative acceleration.

In fact, you can experience somatagravic illusions anywhere. One cheap and easy way of producing them is with a so-called Bárány chair, one that simply rotates the subject in the horizontal plane for a while, after which he usually experiences disorientation. (Bárány won the Nobel prize for this invention and for his research into this aspect of human physiology: the role of the inner ear in maintaining balance.) Try this with a common or garden-variety office chair, putting on a blindfold and then having someone whirl you around. Stopping the chair usually results in the blindfolded subject being certain that he's now whirling around in the opposite direction, because that's what the fluid in part of his vestibular system is telling him.

Another easy way to induce disorientation is to use this childish trick of having the subject put his forehead on a baseball bat and then shuffle in a circle around it, afterwards trying to stand up and walk straight, when hilarity ensues.

We had a sim with a small problem with the visuals, when starting to taxy made the horizon bob up and down just a few degrees before settling down. That always hit me right in the pit of the stomach. My ears were arguing with my eyes then about who was correct: minor disorientation.

Another sort of disorientation is looking at a single-point light source in a darkened room, when the point of light will begin to move after a while. There your ears are not telling you that it's your head, not the point of light, that's moving.

It's good to know that most people do experience disorientation, that it's a normal human experience. I suppose that some people might think that it's some sort of weakness or defect that can't happen to them, so that when it does happen then it goes ignored, along with whatever the flight instruments are trying to tell him.

[Kulverstukas]

Some interesting information from Denis Okan (S7/Globus)

Collecting bricks: repost by lx_photos (http://lx-photos.livejournal.com/253706.html)

1. The first go-around (after which they diverted into the waiting area) performed due to wind shear.

2. Before the second agreed that in case of unsuccessful approach will divert to alternate with climbing to FL80.

3. The second approach manual. Vapp was set at 10 above Vref (according to wind check must be 10 lover, but it did not play a role).

4. A/C was not stabilized at 1000ft and below 1000 after a short discussion, the crew began GA.

5. During the whole approach FO, apparently, was more in the contour than PF. He constantly helped Capt., prompted about actions etc. In general, seems FO was in leading role. PF was tense, he lacked focus, for example, asking questions, if the height set to 8000 at which FO answered - look, here it is.

6. During the GA the Tower transferred them to Area frequency. At this point, FO was trying to suggest something to PF, but apparently the need for communication with the Area distracted him completely.

7. After that, the situation is unfolding rapidly, FO does nothing but tries to convey information to the PF about his incorrect actions, but the time and height was not enough.

Sorry for loose translation :(

[RatherBeFlying]

I was RS in a Viscount simulator when LS got us inverted at 16,000'. The white on black AH did not help.

I spent the next 16,000' telling him we were inverted.

Hearing can shut down in a high stress situation. If there's no appropriate response to two communications, it's time to announce incapacitation and take over control.

Simulator sessions need to include incapacitation scenarios and discuss the subtle cases as can and does happen with disorientation.

[Capn Bloggs]

subtle cases as can and does happen with disorientation.
The Icelandair 757 incident at Oslo in 2002 is a case in point:

REPORT ON THE serious incident to icelandair BOEING 757 (http://911research.wtc7.net/cache/pentagon/analysis/theories/aaib_757incident.html)

Note, in particular, the control column movements at 1.1.14.3 and 1.1.14.4 and finally, the FO saves the day at 1.1.14.5.

[PBY]

Bloggs, thanks for this report. I have seen this problems in simulators. It is very easy in a simulator to pressure a crew into many problems, as I have control, as an instructor over the weather. I have seen again and again the inability of the crew to even look at the groundspeed, notice the wind and know the appropriate descend rate to stay on profile or to know if they are going to descend in time. This seems to be these days a knowledge only few knows. If you read my post, according to my estimate there is a 8/10 chance, that you are also very weak in planning a descend and also your scanning ability of instruments.
May be there is time to put pressure on training departments. Instead of paperwork audit why there is no practical audit of the training techniques in the sims by somebody competent? If the training departments need to "loose some face" so be it. It is better than loosing passengers.
Thanks Kulverstukas for your report. I think it further stresses the point, that captain was not comfortable in manual flying skills. If the report is true, he was overwhelmed and in tunnel vission. His sensory system could not even handle more info, such as being able to check a set go around altitude.
I am not making my post to make pilots feel bad. I am just stating there is an very easy solution to all of this. It is called a competent training. But how can a bad training department find out they are bad, if they have not encountered in their life good training in the past?
I was in a small flight school the other day watching instrument training in a cheap fixed simulator. It was so refreshing to see the young instructor teaching properly an instrument scan.
I guess we need a help as an industry. There must be some experienced manager, not even related to aviation, who could, based on experienced advise from capable pilots somehow overhaul the system. It is so obvious to me, that the fix would not cost the airlines more money, as they are spending them on incompetent training anyway.
But the non-flying management does not understand the problem, because the incompetent training department is not going to come to them and say they need help.
I am a captain. I do not like to be a passenger on aircraft. I know what my happen should the crew be put into a situation where manual flying competence and good airmanship is needed.
May be I need to by myself a book of "How to loose a fear of flying as a passenger" instead of trying my Don Quijote effort of overhauling the system.
And pilots are not stupid. They improve quite rapidly, if they are exposed to proper training, which is unfortunately almost non existent in airline establishment.

[604driver]

I think it further stresses the point, that captain was not comfortable in manual flying skills. If the report is true, he was overwhelmed and in tunnel vission. His sensory system could not even handle more info, such as being able to check a set go around altitude.

I think it could also stress the point that Capt MAY have been trying to fly the HUD with a set of circumstances / energy vectors / Accelerations, he was not familiar with.

[andrasz]

The Icelandair report is a sobering read, could have been a very similar scenario, just with a less alert FO

[73qanda]

I think it could also stress the point that Capt MAY have been trying to fly the HUD with a set of circumstances / energy vectors / Accelerations, he was not familiar with.Or that he was so tired that he was not processing the information presented to him ( both audio and visual) as he had two hours previously. Or both.

[porterhouse]

Capt MAY have been trying to fly the HUD with a set of circumstances / energy vectors / Accelerations, he was not familiar with.
Far fetched speculation.

[Centaurus]

Worth reading a parallel discussion currently in Tech Log forum and which goes into stab trim operation associated with go-around procedures. In particular the handling of the pitch up that occurs during a go-around in a 737.

http://www.pprune.org/tech-log/576817-pitch-trim-poorly-understood.html

[Jwscud]

I tried timing pitch trim runs yesterday on the ground with flaps extended. 5 seconds of manual pitch trim activation equates to around 25% of the total trim travel or between 4 and 5 units of trim on the scale.

I am making the unverified assumption that the trim rate would be identical in flight with associated aerodynamic loads.

[SLFinAZ]

I'm still confused that you have a plane in the meat of it's flight envelope with known attitude and power settings in what should be a stable climb and it all goes to hell within seconds?

The plane is not in a complex environment in a highly automated state where the pilots focus is elsewhere and they are relying on the automatics and have degraded scan and over reliance. It's not AF where the senior pilot was off the flight deck, the least experienced had the controls and poor CRM prevented the more experienced pilot from intervening while he might have been able to recover...

A qualified pilot flying a functioning aircraft manually during a "routine" (in the sense that it was briefed and trained and not an emergency) lost control during what should have been a simple pitch and power maneuver that could be flown my almost any general aviation pilot with suitable training.

By that I mean that if you took a typical 500 hour GA pilot and gave him 40 hours of 737 sim training and 20 hours of manual circuit flying (take off, landings, approach and departure patterns, touch and go circuits etc.)

He would be able to pass an aborted ILS approach at any point it was called by a check airman. Or is this a wrong assumption?

[framer]

Depends, has the 500hour GA pilot done two years straight of rosters that don't account for circadian rhythm and expected to do the missed approach at 4am after six hours in the seat?

[A37575]

By that I mean that if you took a typical 500 hour GA pilot and gave him 40 hours of 737 sim training and 20 hours of manual circuit flying (take off, landings, approach and departure patterns, touch and go circuits etc.)

He would be able to pass an aborted ILS approach at any point it was called by a check airman. Or is this a wrong assumption?

SLFinAZ is online now Report Post


But if the same GA pilot had spent 95% of his flying in a 737 on automatic pilot and in the simulator and certainly very few actual go arounds in IMC, then it is an entirely different story. Probably thousands of current of 737 pilots and indeed other current types are in the same boat. But get the combination of turbulent night IMC weather and looking at a possible late diversion to an alternate and add the fact the crew have long lost manual flying skills they maybe once had, then the Swiss Cheese holes lined up and we now see the tragic result.

So much depends on how good the pilot can fly an aircraft manually on instruments. Unfortunately, most airline crews nowadays are almost totally automation orientated or forced into it by company rules that stifle hand flying even under the most benign conditions.

[chuks]

Conventional wisdom was that it took an experienced pilot who had only flown with "steam gauges" about 300 hours to get past that "What is it doing now?" stage with a glass cockpit. "Results may vary," of course. Some guys pick it up right away, but others never do quite catch up to the airplane.

Modern displays can present one hell of a lot of information all at once so that you need to understand what you are looking at and what to pay attention to. These displays can easily overload someone with information, when that might turn out to be part of the problem with what went wrong this time.

[RAT 5]

Modern displays can present one hell of a lot of information all at once so that you need to understand what you are looking at and what to pay attention to.

Having come from the 'steam gauges' to the screens in mid-80's I understand the problem. The solution was training and guidance of where to look and how to interpret all the data. This was well demonstrated when later I transitioned from an a/c with conventional ASI & fast/slow speed tape on PDF to a no ASI and full speed tape with all the bugs & symbols. I did not fully understand all the great data being shown on the speed tape and how to interpret it. FCom Vol 2 was not the most helpful. A long sector with a knowledgeable trainer solved the problem and opened my eyes to a whole new world.
When I had the chance I tried to spend time with students to explain the hidden delights of EFIS/EICAS. Sadly some were not too interested. They'd learnt what to do in TR with rigid SOP's and full use of automatics, but IMHO had not been taught how to monitor the automatics via the EFIS. Their scan was tunnelled and slow. The root cause of the problem lay in shallow initial training followed up by incomplete and superficial line training.
Lack of time and discretion did not allow the students the chance to do a real raw data sim session as introduction to the a/c. That could have introduced a real scan; indeed would have necessitated it. ROOT CAUSE.

[chuks]

There's a lot of old-fashioned flying ability that has gone lost, particularly because a lot of the younger generation are "direct entry," never putting in those long hours doing flight instruction, and poling some bug-smasher with no autopilot and rudimentary equipment in crappy weather. (This always makes me think of that guy hung in chains who shouts that, by God, it's taught him to respect the Romans!)

On the other hand, a lot of the younger guys are much more at home with all this computerized stuff, so that it's not all negative.

There's a lot of room left for self-improvement, evenings spent looking over training material instead of watching dwarf porn on the pay-per-view, while I think that encouraging hand-flying when conditions permit might be a good idea.