B-738 Crash in Russia Rostov-on-Don

[TypeIV]

After that long time in a bumpy, noisy, dark and tight space you are only at a fraction of your normal capacity. We all have our tricks to try to keep up but ultimately, we are not made to handle that amount of information efficiently at that time in the morning at that speed. Scanning slows down significantly and eyelids starts to feel heavier by the hour and the situational awareness declines drastically.

[Phileas Fogg]

With a Crew Scheduling background I studied that F/O's roster:

The amount of duty days and duty hours, I presume, fall within the FTL's ... If they are excessive then it is the FTL's, not the Crew Scheduler nor computer programme, that need changing.

Presuming 2 consecutive days off in 14, 8 days off in 28 then an 11 day roster period, with only one day off, has been 'cut' as 'worst case scenario', as 'scare tactics'.

My only criticisms are:

1. A restricted 'Captain Only' destination has been scheduled as a 12.75 hour night duty, and:

2. The F/O had a 20 hour rest period prior to this night duty.

What would I have done:

1. As a Crew Scheduler:

I'd have scheduled the F/O for little more than minimum rest prior to this duty or I would have brought him in fresh from days off to perform it, and/or:

2. As a Commercial Manager:

I would schedule the route as a daytime duty whereas the crew report for duty at the optimum time of day.

3. As a Flight Operations Inspector:

I would ensure that (1) and/or (2) are acted upon and put in place.

[Say Again, Over!]

From wikipedia article about Somatogravic Illusion

Vestibular/somatogravic illusions

Somatogravic illusions are caused by linear accelerations. These illusions involving the utricle (https://en.wikipedia.org/wiki/Utricle_%28ear%29) and the saccule (https://en.wikipedia.org/wiki/Saccule) of the vestibular system (https://en.wikipedia.org/wiki/Vestibular_system) are most likely under conditions with unreliable or unavailable external visual references.
Inversion illusion

An abrupt change from climb to straight-and-level flight can stimulate the otolith organs enough to create the illusion of tumbling backwards, or inversion illusion. The disoriented pilot may push the aircraft abruptly into a nose-low attitude, possibly intensifying this illusion.

[TypeIV]

I agree.

The problem is that the operators want less restrictive FTL in order to be "flexible" in contingent situations. This flexibility is then used to its maximum in order to keep the competitive edge and profits to a maximum.

The authorities say it is up to the operators to use common sense but at the same time allowing dangerous rostering just in case, the operators in turn say that the authorities allow dangerous rostering and therefor they have to do it to keep the greenbacks rolling in.

"Legal = Safe"

[RAT 5]

Scanning slows down significantly and eyelids starts to feel heavier by the hour and the situational awareness declines drastically.

Those of more experience realise this is happening and adjust accordingly; i.e. concentrate to concentrate and do things a little more slowly and ensure accuracy. The abrupt agricultural application of flight control and/or power is avoided. There is also the realisation that using the automatics will release some tired capacity to manage the operation: ah, but then you need to have a thorough understanding of the automatics. Back to ROOT Cause.
I feel this debate, coming at the same problem from various directions, is going into never ending circle mode. We can go at it forever; we are in violent agreement about the problem, but perhaps not the solution, although there is much consensus. Trouble is none of us are in a position to change anything at root cause level. (that is I've not read a post from anyone who possesses such powers).

[framer]

Trouble is none of us are in a position to change anything at root cause level. (that is I've not read a post from anyone who possesses such powers).
Good point.
How many Airline Pilots are there world wide ?
If there are 500,000 and 10% all posted an IFALPA designed letter from their local post office to ICAO headquarters on the 1st of June that called for ICAO compliant countries to limit 2 crew graveyard shifts to 11 hours for single sectors and 9 hours for double sectors, at least someone would have to stand in front of the to cameras and say that they will think about it.
Fanciful I know but it would literally save lives if implemented and the Airlines would still make their dough.

[andrasz]

that is I've not read a post from anyone who possesses such powers


At present I'm no longer in such a position, but for more than a decade I did possess such powers, and the reason I visit here is primarily to listen and learn. It will come very handy if I ever get called to such high office again.


The issue is far-far more complex, and no, in many cases the airline would not make its dough. The issue evolves around overnight flights with a sector length of 4-4.5 hours, and is linked to night curfews, daily aircraft utilization and crew requirements per aircraft.


For airlines with night curfews at home base, the only way to use the aircraft during this time is to send them out late in the evening and get them home by the time the curfew is lifted. The commercial realities are that these night flights are not only unpopular with crew, but - surprise, surprise - also with passengers, translating into low yields. As a result the maths work out only if the rotation can be completed by a single set of crew, but not if one whole set of crew needs to be stationed permanently at the destination (it is not just the hotel cost, but one full extra set of crew is needed for the aircraft).


The alternative is of course to drop the destination, keep the aircraft grounded at base during the curfew, and operate the aircraft with two less sets of crew (which is what European low-costs typically do, as they do not need connecting passengers to fill half the flight, hence they can afford orphan sectors in the mornings and evenings). But this means that the ownership cost of the aircraft needs to be spread over fewer revenue flights, pushing their cost up. In many cases, without the night flightpair to spread costs (and the 8 hours flight time is a lot), the whole daytime operation may become unprofitable.


No easy answers, and am not advocating anything, just trying to show that the picture is a bit more complex than simply limiting two sector night shifts to 9 hours across the board (and why 9, why not eight or 9:30... ?)

[Phileas Fogg]

Quite right ...

The industry has become run by bean-counting accountants, no matter what the profit margin they want more and more, many shall never be satisfied.

I worked for one particular operator, the commission-salaried commercial manager would receive a sub-charter enquiry, he would come to me/us asking if we had a crew, the reply would be as big a "NO" and it would be possible to give and still he would sell the flight, he thought it was funny, putting the pressure upon us, and the goodwill of the crews, to work their days off on the promise that we'd give them their day off back the next week until the @sshole would sell another sub-charter etc. ... Somewhat fortunately the CAA withdrew that operator's AOC before they actually killed somebody although they did try with the Leeds United FC team!

Another operator I worked for, and somewhat fortunately my Company President was checked out as a Captain although, the joke was, I referred to him as a penguin, i.e. "The fokker's got wings but he won't fly"! On one two aircraft operation I told him we needed 7 or 8 crews to operate it, he decided that 7 or 8 meant 5 until he found himself in some less than desirable hotel in Bombay ... He never disagreed with my crewing numbers again :)

As much as I may disagree with pilots's managing office departments they did a darn sight better job that what the industry has now, call centre mentality muppets wearing brightly coloured tee shirts calling everybody sir whilst serving about as much purpose as a chocolate teapot!

[framer]

The issue is far-far more complex, and no, in many cases the airline would not make its dough. The issue evolves around overnight flights with a sector length of 4-4.5 hours, and is linked to night curfews, daily aircraft utilization and crew requirements per aircraft.
I hear what you are saying andrasz but I disagree. It is only complex at the level you have described.At a level where accountants are trying to eek out a sustainable business model within the regulations. At an Airline management level. Fatigue as it relates to Airline safety needs to be dealt with at a regulatory level and you will find that it reduces the complexity
of the decision making process at the Airline level.
For example, if the rule I proposed existed, the return sector wouldn't be on the table as an option, and all the eeking would be focused elsewhere.
But this means that the ownership cost of the aircraft needs to be spread over fewer revenue flights, pushing their cost up. In many cases, without the night flightpair to spread costs (and the 8 hours flight time is a lot), the whole daytime operation may become unprofitable.
Again, wrong level.
The demise of airlines/ bases who existence relies on the viability of such 'night flightpairs' is a small price to pay and 'the Airlines' will still make their dough....just not those ones.
This is big picture stuff and market forces will naturally resolve the complexities you talk of.
If the situation is viewed in 100 year chunks of time it becomes simpler to understand.
Thanks for you opinion by the way, interesting to see the mindset.
Cheers,
Framer

[portmanteau]

what are "excessive" FTLs ? I submit they only exist in the minds of crews. nobody constructs a crew scheduling computer programme that allocates hours in excess of the
rules, which are well known to everyone and are pretty much the same the world over. When did you last hear of a prosecution of an airline for imposing illegal rosters? This F/O roster looks to be the usual computer-generated version the pilot would have received many days or perhaps weeks before the day in question and the chance of it being illegal is zero. Even if it turns out he had been called out at a days notice, due perhaps to the original pilot's absence for whatever reason, a scheduler would still make sure all the applicable rules were observed.

The FTL rules have been analysed/reviewed/modified/complained about for as long as I can remember, involving all interested parties including pilots and the medical profession. However things have changed more than slightly since the days of laying over on some sunny tropical island for a few days to await the arrival of the next aircraft. Its hard to think that FTLs designed then still fit todays world. Maybe the pendulum has swung too far the other way and the hallowed (and hollowed) phrase of "Safety is our highest priority" should be taken out and dusted off...

[AerocatS2A]

Well obviously they won't intentionally roster illegally, but legal doesn't always mean safe, and when it comes to fatigue some pilots may have more trouble with a roster than others.

Take the example of a company that only does back of the clock night freight. You might find one pilot who can't sleep during the day after duties 1 and 2 but by duties 3 and 4 he's so knackered that he'll sleep through anything. Another pilot on the same roster may not be able to sleep during the day ever, being perpetually tired but not sleepy. A third pilot may not have a problem with any of it; gets home at 7am goes to bed, sleeps for 6-8 hours and gets up. The first pilot gets by and may have to call in "sick" once in a while when the sleep cycle just hasn't worked for him, the second pilot is in the wrong job, while the rules are written for the third pilot.

[Phileas Fogg]

what are "excessive" FTLs ? I submit they only exist in the minds of crews. nobody constructs a crew scheduling computer programme that allocates hours in excess of the
rules, which are well known to everyone and are pretty much the same the world over. When did you last hear of a prosecution of an airline for imposing illegal rosters? This F/O roster looks to be the usual computer-generated version the pilot would have received many days or perhaps weeks before the day in question and the chance of it being illegal is zero. Even if it turns out he had been called out at a days notice, due perhaps to the original pilot's absence for whatever reason, a scheduler would still make sure all the applicable rules were observed.

The FTL rules have been analysed/reviewed/modified/complained about for as long as I can remember, involving all interested parties including pilots and the medical profession. However things have changed more than slightly since the days of laying over on some sunny tropical island for a few days to await the arrival of the next aircraft. Its hard to think that FTLs designed then still fit todays world. Maybe the pendulum has swung too far the other way and the hallowed (and hollowed) phrase of "Safety is our highest priority" should be taken out and dusted off...

Portmanteau,

Many an idiot can schedule 12 hours on, 12 hours off, until 7 day, 14 day, 28 day totals are achieved, what computer programmes cannot incorporate in to a roster, I believe, are 'a life' for the crew member(s).

Just playing by the FTL's one can make a crew member's life a misery, 12 hours on, 12 hours off, split duties etc. etc. etc.

Whenever I would work on a crew pattern, no matter how legal it was, I would question "would I like that roster for myself?" and if my answer was "no" then I would go back to the drawing board to try and try again until I may have found a pattern/roster that I was satisfied with.

Admittedly crew members may be the biggest bunch of complainers but, perhaps they have a point, one can enter the FTL's in to a computer programme but can one enter the human touch?

[RAT 5]

I once had a discussion with my CP. Firstly there was the earlies & lates issue. We'd all seen the videos about owls & larks etc. All that good stuff about not flying if over-stressed or fatigued. (plain over-tired didn't count) I suggested that to improve safety and morale why not let the larks volunteer for earlier & the owls the lates? Or anyone else who's family life suited one or the other. The answer was "there are no favours and you are all the same."
The next point was the roster. The Ops guys and other ground jobs e.g. engineers worked 12hrs on 12hrs off, 4 days on 4 days off, 2 earlies 2 lates. Why could pilots not do the same? We would achieve better sleep in the middle of changeover and still produce the hours. The answer, "you don't work shifts, and FTL's are your rules."
So my mixed bag of duties 24/7 didn't count as shifts, even though I was sleeping when I should be awake and vive versa. Hm!
So the guys on the ground, with their radios & TV's, coffee machines & canteens, plenty of mates to chat to, plenty of space to walk around and avoid broken backs, proper toilets to use; they could work 4/4. Meanwhile, we in our cramped little dehydrating box with no space to swing a cat, never mind exercise your back, and with all its other associated anti-social parameters that are well known, can work 6/2. "But safety and welfare of crews is our top priority." Never forget that. Twaddle.

[langleybaston]

"But safety and welfare of crews is out top priority."

As SLF I would hope that was "passengers!"

[RAT 5]

If crews are safe it follows that pax will be too. I've not known a/c reverse into an accident. But you knew what I meant, I'm sure.

[pax britanica]

Spot on-look after the crews and the pax are taken care of too.

A pilot friend of mine now retired said no one shares the results of a screw up with the 'victims' more than a flight crew.


His corollary to that was 'we are interested in our own safety, if we get there and walk down the steps at the end of the trip so do you' See how long ago that was, pre jettys but the point remains the same and if the crew are well rested and a proper assessment of human factors comes into rostering and trip assignment the pax will be just fine.

As for this thread well , tired, demotivated crew (they were both about to leave) flying to a bad weather, tricky (captains only landing ) two hours holding (how often does that happen ) and the prospect of a long back of the clock slog back to Dubai. It might all be legal and often doable but it doesn't really sound ideal does it

[RAT 5]

Ive been reflecting on the build up to this. There is now discussion about the atmosphere, mental attitude the crew and perhaps tiredness. People have mentioned they had lots of fuel hence the hold. There is also speculation about communications back to mission control about Plan B. People suggest that 2 hours gives lots of thinking time for Plan B & C. However, sending yourself dizzy for 2 hours is not a conducive to clear positive thinking. I can imagine it can be quite the opposite. It allows time for grave doubts, even fear, anger, frustration to subtly creep into your psyche. That is why I'd like a detailed listen into the CVR.
The longest I've held was 1 hour. During that time we worked out 3 options in order of chance of success. We set a time limit to decide and asked Ops what their priorities were if not landing at destination, having told them the alternative options which we had decided upon. (no point is asking them to decide in the comfort of their control room). Once that was decided we had clear thinking and executed the plan. The thought of dithering in never ending circles for 2 hours in the middle of the night would drive me mental. I'm not so sure they would have been in sharp condition on the 2nd approach. Given they made a GA so early it seems they might have been nervous and not confident they were going to succeed . Not a good mental state to be in. I wonder what led them to decide on that 2nd approach.
This does not explain the apparent mis-handling of the manoeuvre, but I feel the effect of 2 hour holding has been glossed over to glibly.

[Chronus]

"I wonder what led them to decide on that 2nd approach." Is the question posed by RAT 5.
Surely after hanging around for two hours they had to make an attempt to land. The early go around would suggest that they were not confident that they would be landing. I do not believe they would have been nervous or tense. They would have been anticipating a go around. But for me in such a scenario the puzzling question is for what reason(s) did they decide to do so on manual. Based on the given information that there was no mechanical or systems failures, it would be reasonable to suggest that had the go around been carried out on a/p the accident would not have occurred.

[flash8]

However, sending yourself dizzy for 2 hours is not a conducive to clear positive thinking. I can imagine it can be quite the opposite. It allows time for grave doubts, even fear, anger, frustration to subtly creep into your psyche. That is why I'd like a detailed listen into the CVR.

Indeed so. Yes it is speculation however I strongly suspect that this will be seen as a contributory factor, were they in the hold out of 'choice'? All leads back to one place.

[RAT 5]

Chronus: If I understand all that has been written FZ's SOP is to fly these kind of approaches manually. Unless they engaged both A/P's (need to be below 1200'agl) then the GA would be GA anyway even if Single Channel was in CMD.

[glad rag]

Indeed so. Yes it is speculation however I strongly suspect that this will be seen as a contributory factor, were they in the hold out of 'choice'? All leads back to one place.
The genie has been let out of the bottle.

[Chronus]

Chronus: If I understand all that has been written FZ's SOP is to fly these kind of approaches manually. Unless they engaged both A/P's (need to be below 1200'agl) then the GA would be GA anyway even if Single Channel was in CMD.
Thank you RAT 5. Does the SOP mean that approaches be flown manually with both A/P and A/T off. With A/P off and A/T on I would have thought not recommended for risks, such as SA loss, potential speed excessive speed excursions caused by pitch changes,particularly in gusty conditions, potential pitch coupling and possible loss of thrust awareness.
I would have thought given the prevailing wx conditions there was every reason to carry out the approach with A/P and A/T.

Has anyone got the FZ SOP . It would be interesting to see what it says.

[ManaAdaSystem]

FZ do single channel ILS with manual landings/go arounds or manual approaches and manual go arounds.
It has been said this approach was a manual approach, which sound a bit weird to me. Could be the case, or just a confusion between manual landing and manual approach?

I am not saying it is the case here, but those of us who have been around the block once or twice know there are a lot of substandard pilots out there.
It was reported that the first officer in this crash was coaching the captain throughout the approach.
Am I the only one who thinks this is strange?

[framer]

If it's true that the f/o was coaching him through then that is obviously a big issue, but I am not convinced this is definitely the case. The media doesn't understand how a flight deck works and it could be as simple as the f/o making appropriate support calls regarding changes in wind, levels passing etc

[ManaAdaSystem]

That could be the case.
This is from kulverstukas post a few pages back. It was translated from a Russian source, but how factual it is, is anyones guess:

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

[Aluminium shuffler]

Chronus, if you're going to criticize decisions from your armchair, which is pretty despicable behaviour given none of us were there and so don't have many of the facts, then at least get the basics right. It has been repeatedly stated in this thread that FZ fly single channel approaches even in Cat III. It has also been repeatedly stated that the 737 autopilot only remains engaged on pressing TOGA if both were engaged, ie a dual channel approach contrary to FZ SOPs.

[Sciolistes]

Has anyone got the FZ SOP
FZ is standard Boeing SOP. For reasons obvious to any 737 pilot, A/T off with A/P off except for takeoff and climbout.

[TypeIV]

You don't want a mistrimmed aircraft in already challenging wind conditions on short final.

The 737 AFDS flies the approach like sh*te and will happilly go into the red speed areas and exceed stabilized approach criteria when the winds starts to get a little gusty, I know this by experience, hence the need to fly it manually if you don't want to divert or be summoned up to the office for tea and biscuits explaining the the nice exerpts.

[maDJam]

Tentative report on FlyDubai plane crash due today (April 19)

A tentative report on the inquiry into the FlyDubai Boeing crash in Rostov-on-Don may be published on April 19, an Interstate Aviation Committee (IAC) spokesman told Interfax on April 18.

"The IAC plans to publish a preliminary report on this inquiry on April 19," he said.

The Interstate Aviation Committee said earlier that the catastrophic stall of the Boeing passenger jetliner at Rostov airport on March 19 resulted from the pilot's shift of the stabilizer into the 'nose dive' position.

While the pilots pushed the control column at the altitude of 900 meters, the plane's stabilizer was moved five degrees to a nose-dive regime, the IAC said. As a result, the plane dived, with up to -1 plunge acceleration.

https://rbth.com/news/2016/04/18/iac-tentative-report-on-flydubai-plane-crash-may-be-presented-on-april-19_585779

[Phileas Fogg]

Having worked 'Operations' for a number of carriers, both scheduled and charter, there are a number of commercial factors that simply don't make sense and please excuse that I don't dredge back thru some 67 pages regarding which buttons to press etc:

1. The outbound load, on a B737-800, was a mere 55, what was the return booked load like because I've worked for many a scheduled carrier where we'd just be looking for an excuse to cancel a flight with just a 30% booked load and something like 70mph winds at the destination would provide us with that excuse, so:

a. Are flydubai a professionally run organisation with trained Operation/Dispatch staff capable of making a judgement call or are they an organisation of tee-shirted muppets calling everybody "sir" whilst serving about as much purpose as a chocolate teapot?, and

b. Upon report did the Captain question the destination weather, was he permitted to question the destination weather proposing cancelling the flight or was he not permitted to propose this and/or he already knew what the answer would be?

And then, having departed and arrived to his destination and conducted one missed approached he went in to the hold, I appreciate that one doesn't enter a hold planning to stay there for 2 hours or longer, but:

a. After 30 minutes, 60 minutes, 90 minutes etc. in the hold "who is calling the shots?". Was a significant weather improvement forecast, or:

b. Why didn't they PDQ divert to, perhaps, Krasnodar, to sit it out there (it is acknowledged that an additional sector reduces allowable FDP by 45 minutes), or:

c. Simply divert to, perhaps, Krasnodar, dump the pax there for road transportation to Rostov, put some fuel on and return PDQ to DXB empty?

As I say there are commercial factors here that don't make sense, who was in charge, managing, this operation or might I already have guessed that it was someone wearing a tee-shirt in charge of this operation?

[Sciolistes]

Phileas, That sounds like a rhetorical question to me.

[Phileas Fogg]

Not intentionally Sciolistes

They departed with a p1ss poor, probably loss making, revenue load to a destination that was, presumably, below weather minima, they were presumably able to legally depart because they had an available alternate.

They were already on a 12.25hr nighttime FDP, rather than use their available alternate they flew around in circles for some 2 hours burning up valuable allowable FDP hours, expensive fuel and engine hours.

I don't know the allowable nighttime (UAE) FDP for 2 sectors but by this time they would have been up to something like a 14.25hr FDP and they still hadn't achieved anything, they still had the 55 pax on board that they departed with, the destination weather was still sh1te and had the flight not had such a catastrophic end where was it supposed to be heading ... It seems that there was no game plan?

[what-to-do]

Phileas,

Welcome the the world that is Flydubai.

There never has been much of a game plan really. The operations department is run by our friends from the sub continent who have a "press on regardless" attitude. If the weather is bad, take extra fuel..... and I don't mean enough for 20-30 minutes of holding, I mean 3-4 tons of fuel.

It is the same for low pax loads too. I myself, have flown with 0 pax on one leg, and not much more on the return one, and this is not a one off either.

Flydubai would rather all flights depart, irrespective of the wx or forecast wx. Having you hold for two hours is nothing here, as it's better than having an a/c diverted where crew and pax need to be put up in a hotel etc.

[Kulverstukas]

20 april 2016



The Interstate Aviation Committee is providing upgrade on the progress of the investigation of the accident involving a Boeing 737-800 registered A6-FDN operated by Flydubai.

An interim report (preliminary reference information) is released and available at the IAC website.

This interim report (preliminary reference information) has been issued in compliance with 2.4.12 of the Rules of Investigation of Accident and Incidents Involving Civil Aircraft in the Russian Federation as well as 7.4 of ICAO Annex 13. The report contains factual information currently available to the investigation team.

The investigation is underway, including collection and analysis of information related to crew training, assessment of crew actions and psycho-emotional status in the course of the accident flight as well as evaluation of the aircraft systems and components operability.

The investigation will be completed with a Final Report.

The information presented in the Interim Report is preliminary and can be subject to clarification and amendment based on the pertinent examinations.

The Report is published in the Russian and English languages. If there is a difference in interpretation between the Russian and English versions, the Russian version will prevail.

http://mak-iac.org/upload/iblock/19b/Interim%20Report%20A6-FDN%20(en).pdf

[Piltdown Man]

Our Russian friends are to be congratulated on an excellent start.

PM

[PJ2]

Kulverstukas, the link doesn't appear to work. Perhaps give this one a try:

http://mak-iac.org/upload/iblock/310/Interim%20Report%20A6-FDN%20(en).pdf

[maDJam]

Another link just in case
https://drive.google.com/file/d/0B-uYrtkEQ2VpZ1p6TXZtNUt6MHc/view


p.5-6
Both approaches (from the height of about 600 m) were performed with autopilot and autothrottle disengaged in flight director mode without significant heading or altitude deviations from the glideslope.

As the crew were proceeding with the approach (as per the FDR and CVR readout), the crew decided to go around again at a height of 220 meters (4,5 km before the runway) and initiated climb with vertical speed of up to 20 mps setting the engines to maximum takeoff/go-
around thrust of 101 – 102% (N1).

One of the probable causes of the go-around decision could have been the 20-knot increase of indicated speed to as much as 176 knots within 3 seconds, which might have been an indication of a windshear.

In the course of the go-around the crew set flaps to 15° and retracted the landing gear.

At the height of 1900 ft (approx. 600 m) after reaching the pitch angle of 18° the pilot flying pushed on the control column, which led to a decrease in vertical acceleration of up to 0.5, increase in forward speed and, consequentially, automatic retraction of flaps from 15° to 10° at a speed of over 200 knots.

The short-term decrease in engine thrust within 3 seconds resulted in decreasing speed and flaps extension to 15°, although the following crew inputs to regain maximum takeoff/go-around thrust led to speed increase and reiterated automatic flaps retraction to 10°. The flaps remained in the latter configuration until the impact.
The pilot flying, by pulling up the control column, continued climbing with a vertical speed of as much as 16 mps.

At a height of 900 m there was a simultaneous control column nose down input and stabilizer nose down deflection from -2,5 deg (6,5 units) to +2,5 deg (1,5 units) (the FDR recorded a nose down stabilizer input from the stabilizer trim switch of the control wheel lasting 12 seconds, while the CVR record contains a specific noise of rotation of the trim wheels located on both sides of the central pedestal), as a result the aircraft, having climbed to about 1000 m, turned into descent with negative vertical acceleration of -1g.

The following crew recovery actions did not allow to avoid an impact with the ground.

At 00:41:49 the aircraft hit the runway about 120 m from the threshold with a speed of over 600 kmph and over 50 degrees nose down pitch.

[flyingchanges]

12 seconds of nose down trim with the flaps out is game over. My best guess is that would change the in trim speed by well over 100KTS.

[captplaystation]

I guess the only remaining question, is whether the question should be "what the hell were they doing/thinking" , or, "what was the machine doing ", & why didn't they, in that case (via opposing input & or stab trim cutout ) stop it.

[Kulverstukas]

I just repost my loose translation from Denis Okan LJ:

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

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

3. The second approach was 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, it seems that 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.

[737er]

5. During the whole approach FO, apparently, was more in the contour than PF. He constantly helped Capt., prompted about actions etc. In general, it seems that 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.



That pops a fatigue red flag.

[Phileas Fogg]

Phileas,

Welcome the the world that is Flydubai.

There never has been much of a game plan really. The operations department is run by our friends from the sub continent who have a "press on regardless" attitude. If the weather is bad, take extra fuel..... and I don't mean enough for 20-30 minutes of holding, I mean 3-4 tons of fuel.

It is the same for low pax loads too. I myself, have flown with 0 pax on one leg, and not much more on the return one, and this is not a one off either.

Flydubai would rather all flights depart, irrespective of the wx or forecast wx. Having you hold for two hours is nothing here, as it's better than having an a/c diverted where crew and pax need to be put up in a hotel etc.

Thanks for explaining that what-to-do, things just didn't add up and you have explained perfectly clearly why they didn't add up.

[framer]

The interim report does clear up a few things that have been debated on the thread so far.
From my reading of it;
1/ Both approaches were flown with no autopilot and no auto throttle using flight directors.
2/ The aircraft was quite light, it departed at 68T so would have been about 54T at the time of the accident ( assuming normal profiles and not accounting for icing etc).
3/ the c of g was not aft, it was well forward.
4/ They carried 10kts on Vref
From my calculations Vref would have been 133 kts so Vapp at about 143.
The report has full thrust manually set and 18 degrees NU giving 4000fpm climb with airspeed increasing through 200kts and blowback to flap ten. All of that makes perfect sense, it is the performance one would expect out of the machine and why a well rested NG pilot would only set about 85% N1 in these circumstances .......unless of course he had just handed in his notice due to years of fatiguing rosters and it was four in the morning and his brain was so sluggish that he hadn't even thought about what thrust to set in the event of a go-around .....in that case everything might happen so fast that he would struggle to to process it all, he might even be more suseptable to seat of the pants illusions and be quite confused.......but it's all legal of course, must be the pilots fault.
Ps it's worth remembering that the same crew conducted a successful missed approach two hours earlier in similar conditions .

[ipilot86]

Setting full (maximum) thrust is a Boeing procedure in case of windshear escape maneuver - refer to B737 QRH. When crews are trained in the sim, this action is required from them.

[safelife]

If one was ever wondering how long the permissible duty time should be, according human performance, through the night, with pre-existing fatigue, here you have it.
The limit would be somewhere between the first approach and the second.
An outbound return flight should never have been scheduled in the first place.

[olasek]

Ps it's worth remembering that the same crew conducted a successful missed approach two hours earlier in similar conditions .
Frankly I don't think it is worth anything, worth remembering, etc.
With pilots' deadly errors you can always show them operating flawlessly 10 mins, 1 hour, 2 hours, etc before the accident.

[framer]

I think it is worth remembering from the point of view that the crew were capable of doing this manoeuvre successfully. To me this means there was likely a change in their performance capabilities over that two hours. ( not really surprising though is it).

[framer]

Setting full (maximum) thrust is a Boeing procedure in case of windshear escape maneuver - refer to B737 QRH. c
That is a good point.
If it was another wind shear go around ( I think the report indicated either a predictive or actual winds hear warning for the first go around) then they got the thrust right but the configuring wrong.
If it was a standard go around, it would appear that too much power was used to get the desired performance, the attitude was within cooee.
Either way, if the previous rostering, duty length and time of day isn't addressed in a transparent manner in the final report it will be a crying sham/e.
Put it this way, if they were truck drivers they would already be in breach of the law regarding fatigue in New Zealand and Australia for not having had minimum rest.

[pattern_is_full]

Maybe it is a language thing, but when we mention "windshear" - shouldn't we distinguish between a microburst (of which there has been no official mention) - and gusty winds without a downdraft? And which maneuver is used for which?

As far as I can tell, this crew broke off an approach due to gusts and in particular a significant tailwind increase. An approach that went unstable and needed a go-around, but not by any means as critical as a microburst (loss of airspeed, loss of altitude).

[ManaAdaSystem]

Setting full (maximum) thrust is a Boeing procedure in case of windshear escape maneuver - refer to B737 QRH. When crews are trained in the sim, this action is required from them.

Correct. I have trained this procedure since I started flying. Every time the same, a life and death situation with a CB or microburst based on data from a real windshear that happened somewhere in the world.
You need to follow the procedure in order not to crash, and you are not given the option to do things differently. The prodedure is hammered into us.

The problem with this is a windshear can be very different from what we train in the simulator. You can get a reactive windshear warning without a CB or TS in sight. All it takes is a loss of 20-30 kts momentarily combined with a bit of turbulence, and the bells go off.
Firewall the throttles and pitch up 15 degrees. Chances are you will get you 20-30 kts back real fast, and then some. A lightweight, powerful 737 will go like a rocket in this scenario. Not a good situation. It is very easy to see a level off with a lot of pitch down and trim.

A WS escape maneuver is not always called for in real life.

[silvertate]

At a height of 900 m there was a simultaneous control column nose down input and stabilizer nose down deflection from -2,5 deg (6,5 units) to +2,5 deg (1,5 units) (the FDR recorded a nose down stabilizer input from the stabilizer trim switch of the control wheel lasting 12 seconds, while the CVR record contains a specific noise of rotation of the trim wheels located on both sides of the central pedestal), as a result the aircraft, having climbed to about 1000 m, turned into descent with negative vertical acceleration of -1g.

I still think the answer lies in that quote.

If they pushed -1g to gain the level-off altitude, and neither were familiar or comfortable with the sensations of negative g, they may well have done something unpredictable. As I said before, I have seen students either freeze and keep pushing, or think they are stalling and keep pushing. And since aeros are not a part of ATPL training, this crew may not have been familiar with negative g at all.

As I have said many times on these forums, at some point in the training, perhaps at upgrade to sfo, all pilots should do a two-week gliding course. Gliding is unique, in that it is all seat of the pants hand flying, in the most challenging conditions. In a strong bouncy thermal you might incipient stall the glider ten times while banking at 45 degrees - it is normal, and the reaction becomes normal. Positive and negative g are a central part of bouncy thermal flying. And of course all the training aircraft are certified for full aerobatics. If you are a (young) commercial pilot who has never flown a glider, I can assure you that you will come out of the course having learned many things about aircraft about aviation, and more importantly, about yourself.

ST.

(note typo error correction - changed 'pulled' to 'pushed')

[wanabee777]

As I have said many times on these forums, at some point in the training, perhaps at upgrade to sfo, all pilots should do a two-week gliding course. Gliding is unique, in that it is all seat of the pants hand flying, in the most challenging conditions. In a strong bouncy thermal you might incipient stall the glider ten times while banking at 45 degrees - it is normal, and the reaction becomes normal. Positive and negative g are a central part of bouncy thermal flying. And of course all the training aircraft are certified for full aerobatics. If you are a (young) commercial pilot who has never flown a glider, I can assure you that you will come out of the course having learned many things about aircraft about aviation, and more importantly, about yourself.

I fully concur!

I believe the U.S.A.F Academy cadets start out in sailplanes.

It certainly gave the GAF pilots an advantage in the early stages of WWII.

[RAT 5]

At a height of 900 m there was a simultaneous control column nose down input and stabilizer nose down deflection from -2,5 deg (6,5 units) to +2,5 deg (1,5 units) (the FDR recorded a nose down stabilizer input from the stabilizer trim switch of the control wheel lasting 12 seconds, while the CVR record contains a specific noise of rotation of the trim wheels located on both sides of the central pedestal), as a result the aircraft, having climbed to about 1000 m, turned into descent with negative vertical acceleration of -1g.

I still think the answer lies in that quote.
If they pulled -1g to gain the level-off altitude,

I know what you mean, but 'pushed' might be more appropriate. But, moving on: I've read that the CVR recorded the captain's concern as to whether 8000 was set in MCP and the F/O's reply that "yes, here it is." If that was indeed the case why was there a control input at 900m to level off? The FD & HUD would still have been in TOGA climb to 8000. And for anyone to hold the pitch trim for 12 secs is unthinkable unless they were in a frozen state of panic. Both these guys had 1000's of hours and therefore I hope were competent & experienced.
I have been in a rapid climb, nose high, high speed ALT ACQ situation (B757) and reducing power was the game saver as the attitude was rapidly reduced, not trim.

[KRH270/12]

I still think the answer lies in that quote.

If they pulled -1g to gain the level-off altitude, and neither were familiar or comfortable with the sensations of negative g, they may well have done something unpredictable. As I said before, I have seen students either freeze and keep pushing, or think they are stalling and keep pushing. And since aeros are not a part of ATPL training, this crew may not have been familiar with negative g at all.

ST

100% True

A negative G sensation can have this effect on pilots unfamiliar with aerobatics.
There have been few strange glider accidents where students nose dived theire plane after a rope failure during a winch launch. They are trained to push hard after a rope failure to regain airspeed to a nose down attitude.
But in some rare cases the students kept pushing into nearly vertical nose dives.

The negativ g sensation triggert a "Warning, something is wrong" and the reaction "Pushing is allways good" even increased the effect and the students pushed the stick forward even more.

[silvertate]

I fully concur!
I believe the U.S.A.F Academy cadets start out in sailplanes.
It certainly gave the GAF pilots an advantage in the early stages of WWII.


Let us be clear about what has happened in much of avaition over the last four decades.

Airlines used to select, pay for, and train pilots. Now it is often whoever comes with the money, and after 200 odd hours (and perhaps only flying in nice sunny Spanish or Arizona conditions), you are in. And then the training is all on the sim, and the sim cannot simulate many things, including fear,* sweaty palms, and negative g.

And the airlines will not pay for anything else. I pleaded with one to pay for extra circuits and bumps on a tailwheel for some underperforming fos (because sims do not simulate landings very well), but they refused. It was too expensive, even if writing-off a set of tyres would be far more expensive. Likewise, a two week gliding course would be about £1,500, full board, plus about £2000 of lost productivity - for the whole career of the pilot. Too much to ask? Yup, too much by far. Ticket prices must be less than £20, so the pilots have never done any real solo flying, by the seat of their pants, with little instrumentation, in real weather conditions - ever.

Good commercial strategy? Of course not, but it keeps the shareholders happy.

ST

* Fear - being well outside your comfort zone.
Try thermalling with 40 other gliders, if you are not fully comfortable with seat of the pants flying and using no instruments.

http://https://www.youtube.com/watch?v=dRFuWRpBa84

https://www.youtube.com/watch?v=dRFuWRpBa84

https://www.youtube.com/watch?v=dRFuWRpBa84

[Jwscud]

The indicated N1s suggest thrust was advanced to the full forward stops.

Having done a previous Windshear go-around, and I suspect with the Windshear escape manoeuvre in his mind the captain (or FO - we don't know if he advanced the thrust levers further as part of "set go around thrust") made an error typical of those made by a fatigued pilot in applying parts of the wrong procedure.

Hand flying the aircraft in those conditions is pretty hard work, the more so if the aircraft is light, and the supposed "coaching" might just be the FO helping the captain out by calling wind changes from the ND or previously briefed configuration points.

Once the aircraft started rocketing away, they were reacting, and probably not in a mental condition to catch up. The duration of that trim input is astonishing - I wonder if in turbulence and with flap load relief activating, he started trimming and froze his thumb on the switch while focusing on handling the aircraft.

What we really need though are the CVR transcript and the FDR data plots.

[Phileas Fogg]

Just out of curiosity what are the crew meals (if any) like on airdubai?

i.e. by the the time they were making that 2nd approach they'd have been on duty some 8 hours, a full day's work for many people, they'd just been flying around in circles for the previous 2 hours doing, pretty much, diddly squat, plenty of time for a nice succulent meat dish meal with all the trimmings to prepare them for the remainder of their night's work, or were they pretty much starved?

[DOVES]

Let me humbly consider the following.

Correct me if I'm wrong: Load factors limits +2,5/-1 Flaps ext. +2,0/0

And we all know what to avoid to respect them.

However: do you have the slightest idea of what can happen in a passenger cabin of an aircraft submitted to negative "g"?
What goes on in a galley?
And in a toilet?
And happens to unfastened passengers and Fight Attendants?
And to pallets/bags in the hold?
I don't!

Do you remember what you should check before you start aerobatic maneuvers?

Among others (area, altitude) AIFRAME!

So I fully agree with post 1330, that of Phileas Fogg
a. After 30 minutes, 60 minutes, 90 minutes etc. in the hold "who is calling the shots?". Was a significant weather improvement forecast, or:

b. Why didn't they PDQ divert to, perhaps, Krasnodar, to sit it out there (it is acknowledged that an additional sector reduces allowable FDP by 45 minutes), or:

c. Simply divert to, perhaps, Krasnodar, dump the pax there for road transportation to Rostov, put some fuel on and return PDQ to DXB empty?

One thing I'm sure of: THIS IS MY ONLY LIFE AND I'M NOT INVULNERABLE NOR IMMORTAL

- Truly superior pilots are those who use their superior judgment to avoid those situations where they might have to use their superior skills.

One more thing.
I remember that in the last flights I made on 73 the co-pilots were taking a nasty habit of trimming pitching up during the flare (ie piloting with trim). Now?
Safe Flights
Romano

[framer]

Having done a previous Windshear go-around, and I suspect with the Windshear escape manoeuvre in his mind the captain (or FO - we don't know if he advanced the thrust levers further as part of "set go around thrust") made an error typical of those made by a fatigued pilot in applying parts of the wrong procedure.
Very possible. I think the data plots would help because we don't know the max pitch attitude achieved. If it is very high then the stab trim input may have been intentional for the whole 12 seconds, ie he kept running it until the nose got back to 15 degrees and by then it was too late as a rapid pitch down was inevitable.

[FGD135]

So, what caused the aircraft to go into a dive?

Here is the answer:

... the FDR recorded a nose down stabilizer input from the stabilizer trim switch of the control wheel lasting 12 seconds

So, that hypothesis by Denis Okan, in the form of the simulator video, has turned out to be deadly accurate. He ran the trim for 11 seconds (with flaps 10).

And the bank angle? Denis couldn't get the same negative G effects in the simulator, so he had to roll on the bank deliberately. On the actual flight, the trauma of the negative G may have caused one of the pilots to grab at the wheel, possibly catching one horn and inducing the roll.

[wanabee777]

Ref post #1355 http://www.pprune.org/rumours-news/576325-b-738-crash-russia-rostov-don-68.html#post9351338,

...Good commercial strategy? Of course not, but it keeps the shareholders happy.

ST


A very sad commentary on the state of our profession.

[KRH270/12]

What stoped the trim after 12s, did the PF release the Trim switches or did the comtroll collum activated stab trim coutout switches kicked in when he started to pull? Und

[Chronus]

At a height of 900 m there was a simultaneous control column nose down input and stabilizer nose down deflection from -2,5 deg (6,5 units) to +2,5 deg (1,5 units) (the FDR recorded a nose down stabilizer input from the stabilizer trim switch of the control wheel lasting 12 seconds, while the CVR record contains a specific noise of rotation of the trim wheels located on both sides of the central pedestal), as a result the aircraft, having climbed to about 1000 m, turned into descent with negative vertical acceleration of -1g.

I still think the answer lies in that quote.
If they pulled -1g to gain the level-off altitude,

I know what you mean, but 'pushed' might be more appropriate. But, moving on: I've read that the CVR recorded the captain's concern as to whether 8000 was set in MCP and the F/O's reply that "yes, here it is." If that was indeed the case why was there a control input at 900m to level off? The FD & HUD would still have been in TOGA climb to 8000. And for anyone to hold the pitch trim for 12 secs is unthinkable unless they were in a frozen state of panic. Both these guys had 1000's of hours and therefore I hope were competent & experienced.
I have been in a rapid climb, nose high, high speed ALT ACQ situation (B757) and reducing power was the game saver as the attitude was rapidly reduced, not trim.
Why level off prematurely would be more to the point. Could this not be the first in the causal chain. Given what appears to be on the face of it, a big heave- ho to arrest the climb in a hurry, an evasive manoeuvre, what could they have possibly been trying to avoid. I would suggest heavy weather seems the most obvious.

[RAT 5]

Why level off prematurely would be more to the point.

That was precisely my question.

[framer]

Why level off prematurely would be more to the point. Could this not be the first in the causal chain. Given what appears to be on the face of it, a big heave- ho to arrest the climb in a hurry, an evasive manoeuvre, what could they have possibly been trying to avoid. I would suggest heavy weather seems the most obvious.
I don't think he was trying to level off, I think he either had, or perceived he had an excessive pitch attitude. Whether that was because of somotogravic illusion or an actual high pitch attitude or a combination of both who knows. I think his goal was to remedy a situation of high pitch while in a state of sensory confusion.

[Kulverstukas]

Why level off prematurely would be more to the point.

That was precisely my question.

Does Tower cleared them for FL80? I think not.

[minimany]

In the report it states that the flaps automatically retracted from F15 to 10 due to increasing speed. Is anyone else puzzled by this or is it just me? The only automatic flap retraction I am aware of is the blowback protection for Flaps 30 and 40. Anyone care to comment?

[TriStar_drvr]

The 737-800s operated by my company have load relief at 10, 15, 25, 30, and 40 flap positions. At flaps 15 the flaps will move to 10 if airspeed reaches 201 knots.

These airplanes have the short field performance feature, where the leading edge devices do not fully extend until more than flaps 25 is selected.

737-800 that I flew at a previous carrier ten years ago did not have this feature nor the load relief at flap positions other than 30 or 40.

[Otto Throttle]

FZ has the short field performance version. The flap load relief is standard.

As for the level off, it was predicted a number of times earlier in the thread that this could be related to the missed approach altitude coded into the FMC. It is entirely possible that this was not deleted or overwritten to match the MCP selected altitude, and the FMC altitude would be giving flight director guidance and potentially confusing further an already confusing situation.

[OzSync]

As for the level off, it was predicted a number of times earlier in the thread that this could be related to the missed approach altitude coded into the FMC. It is entirely possible that this was not deleted or overwritten to match the MCP selected altitude, and the FMC altitude would be giving flight director guidance and potentially confusing further an already confusing situation.

No this doesn't make sense, VNAV would have to be engaged which is highly unlikely. Even if VNAV was used for the approach, and TOGA not pressed, the FD would have been pitching all the way down as soon as the aircraft climbed away from the approach path until the MAP.

[framer]

Ozsync is correct. The pitch mode will remain in TOGA until a different pitch mode is selected or ALT ACQ engages based on the MCP setting. The flight director should pitch for ( in this case) flap 15 speed for MAUW and remain in TOGA.
There seems to be an assumption that he was definitely trying to level off, I think he may well have just been trying to fly the nose back to a reasonable attitude and overcooked the trim element. Ie he kept running stab until he actually had about 15 degrees pitch at which point the machine was trimmed for 300kts.

[Chesty Morgan]

I might have missed it but wind shear go around and flap 15?

[FullWings]

I might have missed it but wind shear go around and flap 15?
It appears to be a normal full power GA rather than a WEM as flap was reduced and the gear raised.

The report says that thrust was reduced after the flap overspeed protection activated, then the thrust was put back to TOGA shortly afterwards. There was a brief period where the flaps came out again until the overspeed condition returned.

What would you be experiencing on the controls if you were flying? As the aircraft is accelerating past its trim speed, there would be an increasing nose-up moment. Reducing the attitude while keeping the power on would only exacerbate the situation. At that point, recovery is only possible by removing power and/or increasing pitch (or retracting the flaps) but the opposite was done.

The -ve g into the ground is the only real clue as to why the wrong control inputs were being made. The aircraft was about as far from stalling as you can get, yet it was being treated as though this was the condition. Reduced/negative g sensitivity? Can’t rule it out yet...

It’s possible the final roll was caused by asymmetric damage to the flaps as they were well into the overspeed regime.

[Chesty Morgan]

Thanks FW. Do we know if they actually had a WS warning?

[RAT 5]

Thanks FW. Do we know if they actually had a WS warning?

Back to the CVR being very important. Not only will it show a 'state of mind' before the event, it will give insight into why and perhaps how the GA was made. The FDR only shows the technical parameters. Many people are focusing on the human factors here.

[FullWings]

According to the report:
they informed the ATC officer of windshear on final (based on the on-board windshear warning) and went around climbing to FL 50 (1500 m), then climbing again to FL 80 (2450 m) to hold.
This is on the first, successful, GA.

They (MAK) have this to say about the second attempt:
One of the probable causes of the go-around decision could have been the 20-knot increase of indicated speed to as much as 176 knots within 3 seconds, which might have been an indication of a windshear.
If they can discern the trim wheel motion on the CVR, they’d have certainly picked up a WS warning, so it seems reasonable to assume there wasn’t one.

[ManaAdaSystem]

Not every WS will generate a reactive WS warning.
It is quite possible they had a WS strong enough to put them outside the stabilized approach criteria, triggering a go around.

[Chesty Morgan]

In one case you get WS guidance in the other you don't. Hence my question.

[RAT 5]

It is quite possible they had a WS strong enough to put them outside the stabilized approach criteria, triggering a go around.
At what height is your landing gate for stabilised approach?

[Fly26]

Also the trim system has a low and high speed criteria dependant upon whether the flaps are up or down, so with the flaps out as in this case the 12secs of trimming would have occurred at the high speed rate from the trim system thus compounding the issue...:(

[Mr Optimistic]

Slf: I understand this was a cptn only approach. Assuming an emergency hadn't been realised, at what point after aborting can the FO legally take over ?

[Chronus]

Thanks FW. Do we know if they actually had a WS warning?

Back to the CVR being very important. Not only will it show a 'state of mind' before the event, it will give insight into why and perhaps how the GA was made. The FDR only shows the technical parameters. Many people are focusing on the human factors here.
Human Factors.

This begins with an understanding of the reason(s) for the go- around. The point touched earlier in the thread was the apparent " early " or "premature" decision to abandon the landing attempt. I would suggest the only reasonable conclusion that may be ascribed to this decision is for safety reasons. For reasons yet unknown, but which hopefully will emerge in due course, the crew decided it was unsafe to continue with the decision. Perhaps the CVR transcript will reveal whether this was in the landing brief. If not, then the possibility arises that the actions lay in the single mind of the PF and must therefore been unilateral, with its attendant risks of uncoordinated responses of the crew at a time when swift coordinated action was required most.

[4runner]

I might have missed it but wind shear go around and flap 15?

Yes. That's the go around/missed approach configuration. A windshear escape maneuver is maintain current configuration.

[Say Mach Number]

Fly26 is absolutely right and demonstrated this in the sim recently the rate at which the trim moves when the flaps are extended is very fast indeed as opposed to when flaps up.

Most 73 drivers probably know this and some don't but next time in the sim ask your instructor to do it and see the effect!

Also reading some of the detail it does contain some of the factors I have observed more and more in the sim especially with new pilots and some old but the tendency to fly with aircraft with trim and treating the trim as the primary flight control.

Instead of using elevator to it best effect the easy thing is just to thumb the trim and keep trimming. You will certainly get a response from the aircraft but not necessarily the one you intended - perhaps!

[furbpilot]

There is no way any medium experienced and psycho physically fit pilot would trim him self into the ground unintentionally and while climbing during a GA or WS escape. I [personally think one of the pilot probably the PF become suddenly incapacitated and the other had no time to recover or a runaway trim condition occurred that due to fatigue they were unable to deal with it.
For those not really acquainted with modern commercial aviation slavery style think about what your driving performance would be if you slept only a few hours in the afternoon ( family permitting) and than embarked in a 5 hours journey in the middle of the night while there'll be no way you can get out of your car for a piss and a breathe of fresh air during this time and you'll have the perspective of having to pass trough a tunnel which is only five inches larger than your car at 200 km per hours at the end of your trip..that renders the idea more or less of the condition they were operating .. I believe.

[Chesty Morgan]

Yes. That's the go around/missed approach configuration. A windshear escape maneuver is maintain current configuration.

I know, hence my question.

If they went around for wind shear why did they change configuration?

[framer]

The omission from the preliminary report of a windshear warning for the second approach ( as opposed to the first where they identified it) has me thinking that the go-around decision was not based on a windshear warning and that a normal go around was the intention. This is backed up ( in my mind) by the raising of the gear and selection of flap 15. The fire walling of the engines is an issue. This speaks to the state of mind of the PF and introduces challenges to flight path / airspeed / attitude control that are significant.

[Chesty Morgan]

Framer, agreed, it's confusing. Firewalling the engines is part of the WEM on the NG, reconfiguring isn't. What I want to understand is if they went around for WS (warning or pilot identified) why reconfigure. If they intended a standard go around why firewall the engines.

[helen-damnation]

If they went around for wind shear why did they change configuration?

Possibly a "Windshear Ahead" warning which would allow for a config change?

[Jwscud]

Chesty, as I have speculated, the Windshear Escape was foremost in the flying pilot's mind, and he simply fire walled the thrust without thinking, which is a typical fatigue related rule-based error.

The application of beyond rated thrust in a very light aircraft was clearly the initiation of the sequence leading to the loss of control and a rational explanation for it I suspect will not be forthcoming.

This may simply have gone around because the speed was impossible to control, and the chances of a successful approach were low.

[Chesty Morgan]

That's definitely a possibility and in the WS case it is the correct action, with the thrust levers at least, so NOT an error. The error would be to reconfigure IF a WEM was initiated. You won't get more than rated power on the NG if you firewall the TLs you'll simply get TOGA thrust.

[Jwscud]

Slight slip in terminology - sorry. Full 26k takeoff thrust is less than the full forward stop, but full 27k Max rated thrust is at the forward stop ref FCOM 2 7.20.4; what isn't obvious to me either from FCOMs or my FMC guide is whether full GA thrust is 26k or 27k - from thrust lever position at GA thrust I would assume it is 26k?

Hopefully the CVR evidence will indicate whether a Windshear or a normal go-around was intended.

[RAT 5]

Guys: they had only 55pax and some fuel. At that weight there was more than enough thrust for any WEM; but at their height would they have received such a warning? Back to CVR. Or could it have been just a "WS ahead?" Back to CVR. If they were light and gave full power for a WS ahead warning they were in deep shtuck. If this was the case it is almost as though they were primed for this eventuality. Trigger happy? If so, and if they'd experienced it once, and if they had an escape route to a safe haven, i.e. a Plan B in hand, then it is not a rushed manoeuvre. It would have been "let's have another look-see, and if it is the same as before, and because we are both dog-tired, we'll make another GA nice and smoothly and F-Off to that cosy ALTN just done the road. We have their Wx and we have the fuel, and we can look forward to a nice soft warm bed." Good CRM them stipulates that "What do you think?" would follow. Reply," fine by me let's do it. What are they going to do? Fire us? We're leaving anyway."
The CVR will tell volumes.

[Phileas Fogg]

we'll make another GA nice and smoothly and F-Off to that cosy ALTN just done the road. We have their Wx and we have the fuel, and we can look forward to a nice soft warm bed." Good CRM them stipulates that "What do you think?" would follow. Reply," fine by me let's do it. What are they going to do? Fire us? We're leaving anyway."

Interesting point but how may outback Russian city hotels have you stayed in to describe them as "nice, soft and warm"?

I'd much rather get the job done and foxtrot oscar back to the relative luxury of Dubai.

[Alycidon]

Would anyone know if the HUD is used during the go round? I've seen them in the sim, but have no idea how it is used.

I have a feeling that if the HUD was used for the missed approach, then the attention of the PF is focused away from the PFD and toward the visual cues outside. This is fine for a low vis landing, but climbing at night into the overcast with the landing lights shining into the cloud, this would be most disorientating.

If the aircraft is accelerating, pitching up and climbing into cloud at night, then I would imagine that the PF would find it very difficult to focus on the pitch attitude unless he concentrated hard on the PFD. It is hard to explain why the previous go round went to plan, but the second went badly wrong, the only difference possibly being that the first go round was due to windshear and the FD pitch commands were followed, but on the second go round, the PF was distracted.

[Centaurus]

but climbing at night into the overcast with the landing lights shining into the cloud, this would be most disorientating.


You can say that again. It beats me why pilots persist in leaving landing lights on in cloud. Swirling cloud patterns can quickly affect concentration. In the "old" days landing lights were only ever on for initial take off and switched off within seconds of being airborne. For landing they were switched on about 300 ft. Then some bright spark thought why not have the landing lights on at 10,000 ft on descent (off at 10,000 ft during climb after take off). This was supposed to be a good idea for collision avoidance. Sure its lovely to see all these aircraft in the terminal area with landing lights displayed. Handy for ATC to visually see who is coming their way - but not absolutely essential as far as the pilots are concerned if under ATC.

In another life in 737's I have done hundreds of black night blackhole take off and landings and no shortage of night/IMC go-arounds either. However, on go-arounds in IMC at night, it takes less than two seconds to switch the lights off and saves getting distracted and partially blinded by the lights reflecting from cloud. Call it good airmanship. Finally slave-like devotion to FD needles that require total concentration to keep the needles centred on a go-around, can be a real trap as they hide the "little aeroplane" which is the vital instrument on go-arounds. I envy the `aces` who claim they have no problem looking behind the FD needles because I'm buggered if I can without getting distracted.

[Aluminium shuffler]

That's because modern airline trainers and managers will punish their pilots for breaching SOP by leaving the lights off. I had that bollocking more than once, C. :(

[EDDT]

we also have lights on/off at 10.000ft, but during high speed climb/descent,ex. CI100,
I just turn them off. More annoying are the new strobes in A320 Sharklet, they shine very much up front into the cockpit. So I turn them off as well in clouds.

[PJ2]

That's because modern airline trainers and managers will punish their pilots for breaching SOP by leaving the lights off. "What's normal" shifts with time just like other human phenomenon. Originally from politics, the notion of the "Overton Window (https://en.wikipedia.org/wiki/Overton_window)" is a way of examining a range of ideas, (or processes, or procedures, etc.), that the public, (or perhaps any group in which standards guide behaviour) will accept. The notion of "range" encompasses the "heretical" (revolutionary) to the level of "policy", (old hat).

The notion of the Normalization of Deviance, first offered in Diane Vaughan's, "The Challenger Launch Decision", (1996) can be thought of as an objective metric in time as well as a description of human behaviour over time in terms of risk analysis and management.

Years ago flight directors were terrible, and on the DC8/DC9, manually set for pitch, mostly during takeoffs. They were reliable for ILS approaches, however. The habit of "looking through" them was borne from the sense that they really weren't telling you anything important. Today, they are fully integrated and display what the auto flight system is "thinking", so they have value, but both the raw data "in-behind", and an awareness of aircraft state, just as Centaurus emphasizes!

[flyingchanges]

Should be called flight suggester, not flight director.

[PJ2]

Re "suggester", good one!

That's the way pilots should take it, for sure. The value in the Airbus FD, (can't speak for the later Boeings) is that it broadcasts what the auto flight system is thinking and what it would do if engaged. It should be just another tool, and not a compelling master.

The original issue at hand is the possible-noted effect the FDs had on the PF in the AF447 accident, now discussed at length elsewhere.

[Chronus]

It all made sense when we had simple things such as the house lever. Push it down and houses got bigger, pull it up they got smaller. Then came glass cockpits and I really must say those who live in them should not throw stones.

[RAT 5]

So I turn them off as well in clouds.

I was IMC, deep in cloud There was this red light mind thumping ef'ing irritating distracting light show going on outside. I turned off the collision beacon. The F/O said, "are we allow to do that?" " We are now!" There then followed a lengthy discussion about the merits of using common sense. We decided that the rotating red beacon served naff all in preventing a collision; it was causing us no end of distraction, and merited turning off. The realisation from F/O that such deviation from SOP's was possible was astounding; and disturbing.
We survived to fly another day.

[PJ2]

RAT_5, a story well worth posting for those are afraid to deviate even when it is obvious that such deviation is necessary. The present pilot shortage is engendering blind adherence to SOPs for their proven record of keeping things safe while keeping the training footprint as small as possible*. Such programs seem to avoid those very occasions in which thinking, knowledge of one's aircraft, knowledge of normal instrument readings & aircraft behaviour, and airmanship take precedence over slavish adherence to habit, company procedures or published SOPs.

In doing so, the commander had better have a very good reason for doing so, but that's the commander's job and also his/her responsibility (to deviate from SOPs in order to preserve, even if only-potentially, life, limb and property).

In fact, if we adhered strictly to every rule and procedure in the book, we'd never reach our destination on-time.

*anyone here believe that, along with simulator time etc., ab-initio airline-pilot cadet flight schools provide a true sense of the principles of aviation, meaning the fact that the airplane is trying to kill everyone on board and will do so at any time the pilots give it an opening...?

[Deep and fast]

Rat5, turn the beacon off in my aircraft and you turn off the FDR!
Agree with the sentiment tho..

[RAT 5]

I'll add the strobe lights as well to my list to turn off in cloud. Only because it was written as an SOP was discretion allowed on the use of landing lights in LVO's.
I once feigned an epileptic twitch in cloud with the strobes banging away. The look on the face of the F/O was priceless. I urged him to turn them of and made a smart recovery; before I confessed, but the lesson was learnt.

[Capn Bloggs]

I once feigned an epileptic twitch in cloud with the strobes banging away.
Not to mention the poor pax over the wing being driven nuts...

[AerocatS2A]

Should be called flight suggester, not flight director.

As someone who flies an aircraft where the flight director and autopilot are entirely independent and the autopilot doesn't actually follow the flight director all that well, I agree with the general sentiment on flight directors. However, the worst flying I've ever seen in the aircraft was from someone trying to "look through" the flight director. If the flight director AND raw data are all telling you the same thing, then follow the damned flight director! "Why not just follow the flight director?" I ask, "because it's crap" he says, "well, it may not be the best in the business but it's a hell of a lot better than you my friend and all of your problems would be solved if you just followed it." I didn't say that, but I was thinking it!

[fireflybob]

I was IMC, deep in cloud There was this red light mind thumping ef'ing irritating distracting light show going on outside. I turned off the collision beacon. The F/O said, "are we allow to do that?" " We are now!" There then followed a lengthy discussion about the merits of using common sense. We decided that the rotating red beacon served naff all in preventing a collision; it was causing us no end of distraction, and merited turning off. The realisation from F/O that such deviation from SOP's was possible was astounding; and disturbing.
We survived to fly another day.

RAT 5, I'm with you all the way here. I find these stories about the way new FOs have been "programmed" to be very concerning.

There is a huge difference between "doing things right" = management and "doing the right thing" = leadership.

[Sciolistes]

I thought the option of turning off strobes and beacons in IMC if distracting was enshrined in airlaw?

[beardedclam]

Interesting how the few posts I have read here clearly hold first officers in extremely low regard. Were you sky gods ever new? I am a new F/O on the A321 and have seen numerous errors by training captains, and gently "suggested" things regularly to muttered thanks. Reciprocal runways, incorrect STARS, gear up, GEAR UP, GEAR UP Please!, delayed Flap retraction, wrong taxiways, requesting FL ABOVE the Max, Missed FMAs, Flex detention for a G/A which is interesting for a few seconds. Never approaching CFIT or the likes, but worthy of raised eyebrows. We aren't just ballast you know.

[RAT 5]

beardedclam: you are quite right and correct to make your comment. The point I think many of the oldies are making is that much of the training today seems to discourage too much thinking for yourself and stresses more on following rigid SOP's. Rather than criticise the victims (F/O)'s) of this sad state of affairs we are trying to draw attention to the demise of airmanship. I can well understand it appears that the F/O's are being targeted as a generalism, which is unfair. It is all too easy to attempt to criticise 'the system' by commenting on the apparent short comings of the products of that system. Criticise by identifying examples; all too easy. Look at it another way; it's not a criticism of the new order of F/O's per se, but a sadness, on their behalf, that they might have a lesser apprenticeship before command than those of earlier generations.
I hope the captains you guided away from their errors appreciated your input and acknowledged it. All success with your career.

[Chronus]

I thought the option of turning off strobes and beacons in IMC if distracting was enshrined in airlaw?
I don`t know where and how it may be dealt with in Air Law, but it certainly has an important place in air safety. Strobes can cause "Flicker Vertigo ", which may result in nausea, dizziness, headache, panic, confusion, spatial disorientation and even loss of consciousness. Hence warnings on TV for any flashing lights in a broadcast, particularly for epilepsy sufferers. During short segments of flight such as climb and descent, on a/p crew unlikely to be affected. However prolonged use in cloud, such as when in the hold, strobes are best off. After all what is the point, if ATC and TCAS are not up to the job, then it is all too late anyway.

Landing lights, I always thought were rather handy to check for precipitation, especially snow, a pretty sight sometimes.

[Jwscud]

I have also learned as an FO some very good tricks from crusty old Captains. On one night at CAT I minima we got in where aircraft before and after us went around as the Captain had the sense to switch the lights off and we just saw enough to continue and land.

I learn these tricks wherever I can as I'm not bright enough to think of them myself!

[4runner]

Interesting how the few posts I have read here clearly hold first officers in extremely low regard. Were you sky gods ever new? I am a new F/O on the A321 and have seen numerous errors by training captains, and gently "suggested" things regularly to muttered thanks. Reciprocal runways, incorrect STARS, gear up, GEAR UP, GEAR UP Please!, delayed Flap retraction, wrong taxiways, requesting FL ABOVE the Max, Missed FMAs, Flex detention for a G/A which is interesting for a few seconds. Never approaching CFIT or the likes, but worthy of raised eyebrows. We aren't just ballast you know.

So glad you could show up to clean house, oh ye master of 250 hours. A bitter, entitled, arrogant, self promoting FO is worse than ballast. They're a danger. You'll wait until the Skipper screws up just so you can come and save the day and fuel your own ego. You'd secretly crave mistakes and will incite discourse in the cockpit. In the US, guys like this are normally weeded out somewhere between their instrument training and airline interviews. I guess if you don't interview and just pay for your job, a few steps and dues were omitted and there weren't enough cracks to fall through.

[OK465]

You know, in 20 years of instructing on the 727, I've seen.....

FOs bail out Captains,

Captains enlighten FOs, and (gasp)

FEs bail out both the guys with the window seats....

On any given day, you never know, the old bell-curve can be pesky....

[Vc10Tail]

Go Around (or take off rotation)...is essentially a heads down instrument flight maneuver.Might there have been some AHRS or IRS issues here?

The technical name by Collins who manufactured FDs for Boeing were "single cue" (V Bar) or Double Cue.Cue is more like a hint.Director is an order or dictate.The cues come from FCCs.So perhaps the FCCs might have been erroneous?

[Avenger]

It is unlikely the full transcript of the CVR will be released, the FDR will only tell us the mechanical inputs and the fact there was a conflict of opinion means s loss of SA and breakdown in CRM. Why the go around was botched we will probably never know and I suspect the theories will continue. A probe into crew composition and fatigue may help but it appears the lessons of the Staines Trident and other similar have not been heeded after all these years of pompous classroom CRM and buzz word jargon. I'm an old fart but willingly embrace technology, all this looking through the FD and raw data nonsense should be confined to Jurassic park. On the other hand when we ask our trainees and even experienced Captains "what do you EXPECT to see the FD commanding" the blank picture tells a thousand words as they say .As mentioned before, the all engine go around is the most commonly mishandled manoeuvre both on line and in the sim

[striker26]

An Illusion Made FlyDubai Pilots Crash Their Plane Into the Ground (http://www.popularmechanics.com/flight/a20530/flydubai-pilots-crash-illusion/)

"An Illusion Made FlyDubai Pilots Crash Their Plane Into the Ground"

[Avenger]

An Illusion Made FlyDubai Pilots Crash Their Plane Into the Ground"

This is, at the moment, pure speculation and there is no evidence to support this theory, just because many sites are jumping on the bandwagon and repeating this " theory" its does not make it true. When all said and done, this will turn out to be a mishandled go-around and loss of control. If one were to adopt this " illusion theory", in practice we could crash every time we entered cloud in similar conditions.. I for one, don't buy it:=

[Vc10Tail]

OPERATIONS GOLDEN RULES address aspects that are considered frequent causal factors on incidents and accidents.Although developed gor trainees, the Operations Golden Rules ate equally useful to experienced pilots.

They address the following but not limited to:-

* Inadequate situational/positional awareness;
*incorrect interraction with automation;
*overteliance on automation; and
*ineffective crew cross-check and mutual back-up.

Statistical data(source: Flight Safety Foundation-1998 to 1999) show that amongst the most frequent causal factors in Approach-and-Landing accidents as a % of events (might have contributed to FZ981 fate?) :-
*Inadequate decion making .....74%

*Ommission of Action or in appropriate
action .......72%

*Inadequate CRM ....63%

*INSUFFICIENT HORIZONTAL AND VERTICAL S.A.........52%

*Inadequate or insufficient comprehension of prevailing conditions...48%

*Slow or delayed crew action(fatigue correlated).....45%

*Flight handling difficulties (fatigue,incapacitation,correlated)....45%

*Incorrect or incompetent pilot/ATC communication (Altimetry or other maneuvering non compliance)....33%

*Inappropriate interaction with automation........20%

The following 8 Golden Rules apply on normal conditions and,more importantly, in any unanticipated or abnormal/emergency flight condition.

1.Automated a/c can be flown like ANY other aircraft.(stick/rudder/throttle)..Power+Attitude...followed by Trim will yield a predictable performance.Basic Attitude Instrument Flying principles apply. So when things go crazy..disconnect automatics (including the FD) and simply...FLY!

RULE 2. FLY
NAVIGATE
COMMINICATE
MANAGE(Systems,Crew,Pax,ATC,OCC)

In a nut shell FLY snd NAVIGATE mean

Know WHERE you are
Know where you SHOULD BE
Know where the TERRAIN and obstacles are LOCATED.

COMMUNICATE mean attract appropriatecattention to ATC: Pan call? May day (many a time pilots hesitate this and then left too late! And we start questioning the need for CTV recorders to fill the gaps of knowledge)

MANAGE' The contonuation of the flight under the remaining aicraft and dystem support capabilities After performong the required Emergency/Abnormal procedures.

RULE 3. ONE HEAD UP AT ALL TIMES!

RULE4. CROSS CHECK FMS WITH RAW DATA

RULE 5. KNOW YOUR GUIDANCE AT ALL
TIMES (FCU/MCP, FMS
CDU,PFD/FMA,ND.
At all times PF snd PM should be AWARE of:
*Modes armed or engaged;
*Guidance targets sets;
*Aircraft response in germs of attitude,speed,trajectory;and,
*Mode transitions and Reversions.

RULE 6. (THE ...GOLDEN RULE) When
things dont go as expected,
TAKE OVER WITHOUT DELAY!

*FMS (MANAGED) guidance to
SELECTED guidance
*SELECTED guidance to HAND
FLYING!

RULE 7. USE THE CORRECT LEVEL OF
AUTOMATION FOR THE TASK IN
HAND.
It will depend upon the task to be performed:
*tactical (immediate/short term)
*strategic (longer term)
*Flight phase
*Time available

RULE 8. PRACTICE TASK SHARING AND
BACK-UP EACH OTHER.

When the accident report is ultimately disclosed I am convinced many of these aforementioned 8 Golden Rules are likely to surface. Let us hope we not only can learn from them but measures,facilities,training schemes will be instituted expeditiously world wide to mitigate against similar occurrences.

[ManaAdaSystem]

You can throw 100 golden rules at a tired flight crew, and they will still be tired.
What is really simple for a rested crew, can be very difficult for a tired crew in the middle of the night.

When the report is realeased I hope they focus on this, but I am not holding my breath. The roster was legal, you know. Legal = safe. Or so they think.

[Chronus]

Discussion on this thread has developed to focus on human factors. However so far, a crucial element seems to have escaped consideration. That is, whether it falls to be considered UCFIT or CFIT. The human factors relevant to each would involve different cognitive elements. From the most likely will ensue the relevant human factors involved.

[RAT 5]

IMHO opinion what is vital in a crash like this is that ALL the relevant facts are published. No BS white-wash. We, the profession, must demand full disclosure.

[Vc10Tail]

Illusions in flight.

[Vc10Tail]

You can throw 100 golden rules at a tired flight crew, and they will still be tired.
What is really simple for a rested crew, can be very difficult for a tired crew in the middle of the night.

When the report is realeased I hope they focus on this, but I am not holding my breath. The roster was legal, you know. Legal = safe. Or so they think.
Mana ada before trashing posts you are recommended to read them."tired crew" as you remarked is not different to "fatigue" which I implied as causal factors.I was merely driving home a more fundamental point.The whole point of the golden rules is to offer clarity during sttess and chaos..which would benefit especially a "tired crew".

No there are no 100 golden rules...just 8.Do try to keep them in mind....

Roster was not necessarily an issue.Long term fatigue may be.It also depends if the crew and especially the PF if he had any fatigue induced mental or physical activities prior to the flight.Voice on ATC tape does not exhibit alarming levels of fatigue He seemed calm and collected.May God rest their soul in peace.

[ManaAdaSystem]

No trashing, but I have to admit I have a minor problem with the PPRuNe flight instructors who always are ready to tell us all how to fly, and what happens if we don't fall over with praise when they spread the golden nuggets. Or rules.

[flash8]

IMHO opinion what is vital in a crash like this is that ALL the relevant facts are published. No BS white-wash. We, the profession, must demand full disclosure.

RAT 5 is quite right here imho. Whilst I have every faith in MAK, other authorities I have zero faith in at all. The contributory factors may well be the most important issues here and certain parties likely having every intention of having them swept under the carpet.. imho again of course, and based on what we know.

[Vc10Tail]

Mana Ada..nothing happens you just imbelish yourself with your petty argument.Am not an instructor...but a trained investigator.Those Golden nuggets might very well save your neck one day...if you pay attention.

This is a forum for sharinfg Aviation thoughts and ideas.Am not sure whether you are simmer or a flyier but keep ego out of this.So..here i am applauding you for knowing how to fly.You have received severe criticism in your previous posts for your show off inputs where your knowledge perhaps requires additional instruction.A pilot that ceases to learn from others ...is a essentially a dead bird.

[Capn Bloggs]

VC10, you're overreacting. All that airbus stuff about how to fly aeroplanes should be second-nature to anybody proficient in the job. The fact that they are published just means pilots aren't trained properly any more. To be honest, I cringe every time I read that poor-English list of how-to-do-it. Not that I disagree with it, but it's all commonsense and covered by SOPs (eg FMA readouts).

Are you now going to announce that this crew didn't comply with Golden Rule number 6?

[FullWings]

Rule 0: don’t crash.

It will be very enlightening if the full report produces some answers as to why an experienced crew managed to dive what appears to be a serviceable aircraft into the ground in conditions that were not that unusual. I expect we will get a lot of the “how” but be prepared for the possibility of very little “why”, apart from the obvious, e.g. loss of SA and 12 seconds of high-rate ND trim, which effectively sealed their fate.

There could be some clues in what modes the AFDS was in and whether it was being followed or not. There’s also the issue that what you need to do in a microburst (WEM) is very different to encountering positive wind gradient but all training goes into the first scenario.

Humans very occasionally behave irrationally for no apparent reason, probably due to the statistical nature of our neural networks. You can do the same task for years but one day you do it differently for no reason that you can ascertain; tiredness probably doesn't help, either. One also has to ask the question: “would the autopilot and autothrottle have done it better after a long flight and multiple missed approaches?"

[framer]

One also has to ask the question: “would the autopilot and autothrottle have done it better after a long flight and multiple missed approaches?"
How do you propose that it is engaged after 100% N1 was commanded ?

[latetonite]

I do not buy the crew fatigue hypothesis. I would be wide awake in a go-around, especially in bad turbulence and a unusual attitude.

[Aluminium shuffler]

Latetonight, apparently you have been fortunate enough never to suffer fatigue.

[framer]

My thoughts exactly. It's a bit like saying " I don't buy being tired in the last km of a double marathon, I'd be sprinting my arse off".

[Sciolistes]

I do not buy the crew fatigue hypothesis. I would be wide awake in a go-around, especially in bad turbulence and a unusual attitude.
Fatigue does not mean being tired. Yawning does not mean being fatigue. Fatigued means possessing reduced brain function which is often only apparent in hight workload situations.

[FullWings]

How do you propose that it is engaged after 100% N1 was commanded ?
I leave the correct answer to someone type rated as I never flew the NG but if it’s anything like the older ones, arm the AT if it isn’t already, then choose from two taps on the TOGA switches, pressing the N1 button, LVL CHG, VNAV and probably some others.

My point was that if automation is available and would reduce the workload, thereby freeing up monitoring capability, it might be a good idea. It’s very possible that this accident wouldn’t have happened if the AP and/or AT had been engaged...

[notapilot15]

So initial "pilot error" spin didn't gather momentum so now indirectly blaming pilots thru "illusion" theory thru planted reports.

latetonite

Use captain's roster as your itinerary to fly as economy passenger, when you reach home after one week immediately go on a overnight drive.

[framer]

My point was that if automation is available and would reduce the workload, thereby freeing up monitoring capability, it might be a good idea. It’s very possible that this accident wouldn’t have happened if the AP and/or AT had been
Good point big picture, but in my mind after TOGA button and a fist full of thrust in a light 73 there is little hope of being able to engage automation. Control yoke pressure has to be completely released which isn't going to happen when you are struggling to keep the nose from rearing up. Same as on the classic.

[SOPS]

You flew his roster, did you latetonight? For months on end? Don't judge unless you have been there.

[FullWings]

Good point big picture, but in my mind after TOGA button and a fist full of thrust in a light 73 there is little hope of being able to engage automation. Control yoke pressure has to be completely released which isn't going to happen when you are struggling to keep the nose from rearing up. Same as on the classic.
Initially, I agree with you, as it’s likely out-of-trim and somewhat of a handful. However, in the time it takes to get to 3,000’, one would have hoped for an opportunity to sort things out in terms of pitch trim and automation. Even if you just let go and engaged the autopilot, it would sort itself out to some degree - maybe not pretty but at least the stabiliser would be returned to a normal position for the stage of flight rather than trimmed into oblivion.

There was an excess of speed and thrust, so why was the response to pitch/trim down and reapply full thrust? This could likely give the answer but we may never know...

[Sciolistes]

Initially, I agree with you, as it’s likely out-of-trim and somewhat of a handful. However, in the time it takes to get to 3,000’, one would have hoped for an opportunity to sort things out in terms of pitch trim and automation.
Nothing makes sense with this accident.

[RVF750]

totally agree with Framer! The 737 is a blunt instrument in the wrong or tired hands. I guess all airplanes respond far better to smooth application of all controls AND power.

Never been a fan of giving it a handful....

[RAT 5]

But you are forgetting these guys were not novices and they'd done it before. The u$64,000 question is "why was it done differently and like a novice?"

[framer]

However, in the time it takes to get to 3,000’, one would have hoped for an opportunity to sort things out in terms of pitch trim and automation. Even if you just let go and engaged the autopilot, it would sort itself out to some degree
I see what you are saying but I don't think it is practical in this particular circumstance.
I departed two weeks ago at a weight close to what they would have been ( mid fifties) and even with a reduced climb thrust I was holding significant forward pressure on the yoke as we cleaned up and held nose down trim for two or three seconds continuously. That is normal, but I would not have liked to let go of the yoke in order to engage the a/p prior to adding an appropriate amount of trim. This situation would have been much worse because of the thrust applied. What I am saying I guess is that I don't think automation should be used to get out of a situation. It's a great tool to use and may prevent you getting into the situation, but once you are there ( 100%N1 18 degrees NU in this case) then stabbing at buttons is not the answer.
I think this comes down to the PF's brain operating in a degraded mode due to fatigue, which lead to inappropriate actions which then could not be recovered from.
The antidote to illusions is fast reliable mental processing of the visual information presented on the PFD, with good training this counters the 'seat of the pants' illusion. If you are processing information slowly or not at all, the illusion is all you have to act on. So if they do run with an 'illusion' it still suggests fatigue in my mind.

[Chesty Morgan]

I get what you're saying Framer but if it's the last resort, or one of, then podging the AP button might just save the day. It would be counterintuitive and it would take a firm frame of (unfatigued) mind and an awareness of "I've lost the plot" to do in a nose high snafu. But if the worlds falling apart around your ears and you can sort it out then I say podge away.

[framer]

Yeah fair enough. I have a reluctance to see this viewed as an automation management problem as opposed to a fatigue problem I guess. Hopefully time will tell.

[Chesty Morgan]

Possibly it's a bit of both.

[FGD135]

... but if it's the last resort, or one of, then podging the AP button might just save the day.
Autopilot won't engage if the trim is too far out.

[Old King Coal]

FGD135: Almost correct.

On the B737 it's the case that one can only engage an autopilot if there is no control loading on the yoke.

It is for that reason (on the B737 for sure) that it's the PF that selects / presses the autopilot button (as opposed to asking the PNF to do it) as only the PF knows if any pressure is being applied (by himself/herself) to the yoke. Indeed, the engaging of an autopilot is (or should be) the only time that the PF ever makes a selection on the MCP when they are the PF (i.e. during manual flight).

If the PF is applying any kind of control loading to the yoke (e.g. because the aircraft is out-of-trim) then the autopilot will not engage.

The Boeing B737 FCTM also states: "The airplane should be in trim, and the flight director commands should be satisfied before autopilot engagement. This prevents unwanted changes from the desired flight path during autopilot engagement."

For a prime example of f'ing up the activation of an autopilot, look no further than the Ethiopian (ET409) B737 crash (http://www.skybrary.aero/bookshelf/books/1752.pdf) out of Beirut on 25th Jan 2010.

[Jwscud]

The automation management issue in my view started earlier in the approach with the decision to fly the aircraft manually.

I agree with framer that once pointing skywards, it was a handling problem to solve. All the suggested actions are nice zero IAS suggestions but it seems from the moment full thrust was applied, the crew were well behind the aircraft and unable to catch up.

[4runner]

No trashing, but I have to admit I have a minor problem with the PPRuNe flight instructors who always are ready to tell us all how to fly, and what happens if we don't fall over with praise when they spread the golden nuggets. Or rules.

ManaAda...
You obviously do not hail from a Commonwealth nation.

[xollob]

personally I don't think going anywhere near the autopilot on a light weight 737 missed approach is a good idea, as I understand it (I may be mistaken) hitting TO/GA gives you 1-2000ft minute rate of climb, engage the A/P & A/T and now it's going to go for full whack.... in a light weight 737 that is imho recipe for disaster, alt cap, wrong speed set, loads of power off and on etc.... personal preference is to hand fly it all until clean and levelled off and then engage automatics, I put them in sooner though if heavier and not just below the Missed approach altitude,
it would be really interesting to know more about the MCP modes etc e.g. had they pressed the TOGA switch or was FD giving guidance to their approach etc etc.... so much conjecture without all the facts.

[Chronus]

The interim report says the go around was most probably initiated because of w/s. So one would expect it was up on the tv. AP and AT off FD on, aggressive max power is what Boeing says and that`s what the N1`s show. In manual flight pressing TOGA switches activates the WEM, A/T will not move the throttles so crew firewalls them. I would assume this to have been the state of affairs until reaching 900 meters when the nose was commanded to pitch down. Why, to stop the climb, there can be no other reason. So why stop the climb, possible reason is weather, worse anticipated at higher altitude. The actual weather at the time of accident says CB`s base at 1080 meters. Looks to me they may have been attempting to avoid entering an active CB cell.

[FullWings]

The interim report says the go around was most probably initiated because of w/s.
Well, “could have been":
One of the probable causes of the go-around decision could have been the 20-knot increase of indicated speed to as much as 176 knots within 3 seconds, which might have been an indication of a windshear.
But then we have:
In the course of the go-around the crew set flaps to 15° and retracted the landing gear.
So not a WEM as defined by Boeing. More a normal GA with max thrust, maybe to get out of the turbulence/shear ASAP. It went OK until:
At the height of 1900 ft (approx. 600 m) after reaching the pitch angle of 18° the pilot flying pushed on the control column, which led to a decrease in vertical acceleration of up to 0.5, increase in forward speed and, consequentially, automatic retraction of flaps from 15° to 10° at a speed of over 200 knots.
Why? Knowing what was on the FMA would help a lot. Then:
The short-term decrease in engine thrust within 3 seconds resulted in decreasing speed and flaps extension to 15°, although the following crew inputs to regain maximum takeoff/go-around thrust led to speed increase and reiterated automatic flaps retraction to 10°. The flaps remained in the latter configuration until the impact.
So, firewall power and pitch over into the ground.

I’m starting to think that it was a complete loss of SA, at least from the PF and the control inputs were almost random. You’re going too fast, so you lower the nose and add power... Doesn’t make sense.

[Aluminium shuffler]

Xollob: "personally I don't think going anywhere near the autopilot on a light weight 737 missed approach is a good idea, as I understand it (I may be mistaken) hitting TO/GA gives you 1-2000ft minute rate of climb, engage the A/P & A/T and now it's going to go for full whack.... in a light weight 737 that is imho recipe for disaster, alt cap, wrong speed set, loads of power off and on etc.... personal preference is to hand fly it all until clean and levelled off and then engage automatics, I put them in sooner though if heavier and not just below the Missed approach altitude,"

No, that is wrong. 737 TOGA activation gives 1-2000fpm climb with a single push. Only pushing TOGA a second time at least 1 second after the first push gives full thrust GA. Manual GA and subsequent AP and AT engagement will engage in either LVL CHG or V/S, depending on circumstances, but neither is a hardship.

As for others engaging the AP with such an extreme out of trim situation by releasing the controls, that makes me question the qualifications of the commentator.

[framer]

for others engaging the AP with such an extreme out of trim situation by releasing the controls, that makes me question the qualifications of the commentator.
I agree. But there is no other way to engage the A/P on the NG. Ie it won't engage if there is any control input. That's why I think it's a dumb idea. If you're flying manually and get out of shape the A/P is not the answer. ( I imagine you already know that and we are in furious agreement)

[FullWings]

I don’t think anyone is suggesting throwing your hands in the air and making a stab at the AP engage button as an SOP whenever things get difficult.

However, in this particular accident, the aircraft is in a million pieces and everyone is dead. IF they had engaged some sort of automation, would the outcome have been different? It would be very interesting for someone with access to a sim setting it up with the published parameters (2000’, TOGA, 18degs NU, trimmed for 156kts/F15 with the speed at 180kts) and observing what happens. It might not be pleasant but will it save the aircraft, at least for long enough to give the pilots another chance?

[Chronus]

Recurring theme in post is " doesn`t make sense ". If you think within the box well, of course it does not. Most accidents do not make sense, even after all have been explained.
What makes sense here is that the planned landing was not executed, the attempt to level off in the go around could not have been planned. That is when all went wrong, because it was not planned. It could only have been an instant, unpremeditated, spontaneous response to an unexpected event or encounter. Energy management essential in such circumstances must have been precluded by other more pressing priorities.

[Alycidon]

Could it be possible that the PF was pushing on the cc while temporarily suffering from the false pitch up feeling caused by the somatographic effect, and the PM was pulling on the cc having seen the unusual attitude develop, this could explain the long duration of APND trim input. As long as the PF is pushing harder than the PM is pulling, then the main trim will operate in the direction the PF is commanding.

Also, what use is a HUD during a go round, it's designed to allow you to follow the instruments while looking out. Why would you want to look out?

[mercurydancer]

Whilst I can accept all the fatigue issues regarding perception and cognitive ability, what I cannot understand is the two hour delay before making the decision to try and land again.

I'm a professional involved in healthcare and human factors in such an environment. I would have expected that during that two hours there would have been a point where a check was made on the fatigue factors.

[Sciolistes]

Recurring theme in post is " doesn`t make sense ". If you think within the box well, of course it does not. Most accidents do not make sense, even after all have been explained.
No. It really does not make sense! We need the full CVR, all 2 hours of it, to make any sense of what was going on.

[donotdespisethesnake]

The way I read the report, all the factors point to a classic case of somatogravic illusion. Fatigue provides an additional hole in the cheese, with rational thought being pushed back and gut instinct taking over.

I didn't see the interim report mention it, but I think the reported "do not worry" from the PNF may have referred to the PFs perception of excess pitch up. The subsequent "don't do that!" from the PNF refer to the PFs actions in applying ND trim.

[framer]

what I cannot understand is the two hour delay before making the decision to try and land again.
Punitive company culture regarding diverting?
Recordings of communications with company would be interesting.

[dubaigong]

Framer,

Believe it or not but the company told us that the communication has been "lost" or are not availble due to a technical problem that night...
I must tell you that we all laugh when they told us

[TwoHeadedTroll]

I don't know why people think it is impossible that the pilots would not have some lapse of reason. A couple of years ago, driving my car towards a traffic jam, I temporarily forgot which was the accelerator and which the break. It was just a moment of doubt, and happily did not result in an unfortunate result, but I am quite sure this must happen (albeit very rarely) to a lot of people in the wrong situation, especially with fatigue and adrenalin, when automatic responses suddenly get reappraised, or when you find yourself out of the envelope.

[RAT 5]

the company told us that the communication has been "lost"

Were the communications HF or ACARS or Sat phone? Would they not be on some recorder on board? The duty controller that night MUST know what was said. Put them in front of a judge with the threat of perjury hanging over them.

[DCS99]

Framer,

Believe it or not but the company told us that the communication has been "lost" or are not availble due to a technical problem that night...
I must tell you that we all laugh when they told us

What was the "technical problem"?

[Otto Throttle]

Company comms would have been on SATCOM. I don't know if that would be covered by the CVR in the manner of normal comms, but certainly one half of the conversation would be picked up on the area mike.

The nature of the "system failure" with the recording facility in flight Ops, was not elaborated on, but was met with derision by assembled pilots when it was announced. As for putting people in front of a judge, sadly this isn't Western Europe or the US.

In the meantime, it's Ops normal and not one single thing has changed since the accident. Quite literally, nothing. Extraordinary.

[Chronus]

No. It really does not make sense! We need the full CVR, all 2 hours of it, to make any sense of what was going on.
The CVR is sacrosanct, very much doubt it would be released in full for public consumption. I for one would prefer it be only for those in the business.

[Derfred]

Also, what use is a HUD during a go round, it's designed to allow you to follow the instruments while looking out. Why would you want to look out?

You obviously don't use one.

The 737NG HUD is designed to be used in all phases of flight. It reduces the instrument scan rate required during manual flight and generally results in much more accurate manual flight - including a go-around or windshear escape.

[Alycidon]

Thanks Derfred, no I don't use a HUD, so, the question is, on a go round, if you are using a HUD, climbing into an overcast at night with your landing lights on, will you not be distracted by the "cloud rush" as you enter the cloud?

A HUD is designed to allow you to aquire visual cues while still scanning the display, please indulge me and tell me what visual cues you would be looking for in a go round, and how you would avoid this distraction when climbing into the overcast with your lights on?

I would think that the impression of a false pitch up caused by somatographic illusion would be increased if you were seeing the cloud rushing past through the HUD as you climbed into the overcast, particularly if you have just been airborne for 6 hrs in the middle of the night.

Also, the PM does not have a HUD, so does not see the same picture and therefore will be using the PFD when not busy with flap/gear retraction or frequency changing and will not really be able to monitor the PF.

[noske]

The CVR is sacrosanct, very much doubt it would be released in full for public consumption.
What exactly do you mean? The CVR audio is indeed sacrosanct and has never been released for any accident, and I don't think that Sciolistes was asking for that, either.

Regarding CVR transcripts, the national agencies seem to have their traditional preferences. NTSB and BEA usually publish the full transcript (only with words "not related to the conduct of the flight" edited out), NTSC and MAK never do.

So you're probably right, we won't see the full transcript of this CVR, but only because that's how it's done in Russia.

[flash8]

... MAK never do.

So you're probably right, we won't see the full transcript of this CVR, but only because that's how it's done in Russia.

The pertinent parts will be leaked, that is for sure. That is how it is done in Russia.

Our friends in the desert though will have their sticky hands all over this...

[Derfred]

Alycidon,

Thanks Derfred, no I don't use a HUD, so, the question is, on a go round, if you are using a HUD, climbing into an overcast at night with your landing lights on, will you not be distracted by the "cloud rush" as you enter the cloud?

I have about a decade on 738 HUDs. I've never experienced that issue. I use the HUD for every takeoff including night into IMC. If you don't like it, you just shift your eyes down to the PFD - which you might do if taking off into the sun, for example, but it has never bothered me at night in cloud.

A HUD is designed to allow you to aquire visual cues while still scanning the display, please indulge me and tell me what visual cues you would be looking for in a go round, and how you would avoid this distraction when climbing into the overcast with your lights on?

Yes, acquiring visual cues during approach to land is a major design feature of the HUD, but as I said that is not it's only use. Obviously you are not looking for visual cues during a go-around (unless avoiding isolated CU's visually). As I said, the aircraft can be manually flown more accurately in all phases of flight using the HUD because of it's symbology, sensitivity and field of view. For this reason, HUD usage in all phases of flight is encouraged in my airline.

Following HUD guidance is like having a PFD maybe 10 times the size right in front of your eyes, complete with F/D guidance, FMA display, altitude, V/S, radio alt, speed, speed error (from bug), acceleration, all without the traditional instrument scan required on a PFD/ND.

We don't know whether the HUD was used for this manually flown G/A, but I am merely stating my opinion that if it was, it would not have been a contributing factor to the accident or any lack of S/A that may have occurred.

The HUD has a very clear horizon line stretching from left to right, making it very clear to a pilot looking at the HUD whether his nose is pointing up or down. Much more so than a PFD.

Furthermore, in a more extreme UA, the entire HUD picture changes to a circle with an arrow telling you which way you need to pitch in order to save the day. (If the AF447 pilot had one of these HUD's, it probably would have saved him). I digress, however, because it is possible that in this accident that by the time the aircraft was in a nose down UA, it was probably too late to save it.

I would think that the impression of a false pitch up caused by somatographic illusion would be increased if you were seeing the cloud rushing past through the HUD as you climbed into the overcast, particularly if you have just been airborne for 6 hrs in the middle of the night.

As I have said, I disagree. That's my opinion.

The HUD not only gives you pitch attitude, it gives you a flight path vector. If that flight path vector is above the horizon, you are going up. If it drops below the horizon, you are going down. I've already said the horizon is very obvious on the HUD, and the FPV is generally where your eyes will be focused, because that is what you "fly". If using F/D guidance, you fly the FPV to the F/D, rather than attitude as you would on a PFD.

Because you are left with no doubt about where your aircraft is going, I actually think somatogravic illusion is less likely with a HUD because you have better visual confirmation of what your aircraft is doing compared to what your vestibular system might be telling you.

Also, the PM does not have a HUD, so does not see the same picture and therefore will be using the PFD when not busy with flap/gear retraction or frequency changing and will not really be able to monitor the PF.

The PM does not have a HUD, but does see the same information! The PM sees the exact same aircraft pitch/speed/performance just on a different set of instruments. The F/D commands, if being followed during the G/A, will be the same on the PFD as they are in the HUD (different representation, but come from the same AFDS computer). If anything, two sets of eyes on two different instrument representations should increase redundancy (safety) not reduce it.

The PM's monitoring role is no different and no more or less important whether the PF is using a HUD or not. In fact the PM usually sits there in amazement (or jealousy) at how accurately the Captain is flying. The Captain is only flying more accurately because he has a more sensitive instrument that is easier to use (less scanning required).

The only time the PM misses out is during a low-viz manual landing (eg CAT III) because that is where having the HUD makes possible what would only otherwise be possible with autoland. Not relevant to this situation.

I will provide the caveat that the HUD requires training and practice for proficiency. I understand this crew was not new to the aircraft, but I know nothing of this airline's HUD training or HUD SOP's.

[sansmoteur]

Thanks Derfred, really informative.

[Chronus]

CVR

An important aspect of the CVR analysis will no doubt involve the differing nationalities of the flight crew. The captain, a Greek Cypriot and the FO a Spaniard. Therefore English not their mother tongue. Add to this Russian ATC. Might bring into question issues concerning communications, particularly at critical times. It is not always what is said but how it is said that may affect outcomes.

[Alycidon]

thanks Derfred, makes it much clearer, but even more of a mystery now.

[Vortex Thing]

Thank you Derfred. At last someone who knows and uses the HGS ( as some of us do everday) to stop me banging my head against the wall reading this thread. You beat me to the rebuttal there and to be fair did a better job of explaining the usage of the best thing since sliced bread in our cockpit than I would have done anyway!

[Derfred]

Thanks folks. I do have one more thing to add regarding the HUD - without wishing to derail this thread - I didn't mention this in my previous post because I was responding to the specific suggestion of somatogravic illusion.

The HUD exaggerates everything, compared to the traditional PFD, due to it's far greater size in the pilot's field of view, and therefore appears to be far more sensitive. This is why a HUD user can fly far more accurately.

However, this can "appear" to work against you in situations of moderate to severe turbulence. I say "appear" to work against you, but does it really?

For example, many years ago while I was learning the HUD in the simulator, we had to practice a severe approach windshear encounter using the HUD.

On the 737, the windshear escape manoeuvre, (after performing initial actions such as maximum thrust, 15deg pitch) recommends following F/D guidance - because the F/D has a "windshear mode" which gives very useful guidance. On the HUD, the F/D (or guidance cue as it is known in the HUD world) appears to dash all over the screen - as it responds immediately to every turbulent aircraft pitch and yaw - to the point where attempting to follow it appears to become an exercise in futility.

I said as much to the instructor after the event, having concluded already that I basically had no control over the aircraft using the HUD. He then asked the F/O what he thought of my efforts. The response was "extremely well handled". According to his PFD, I was flying the F/D very accurately, and the whole manoeuvre was very well flown.

The moral of this story is that using the HUD in severe turbulence or windshear might make you think you are flying badly, but in fact you are not. Your negative self-assessment is just due to the sensitivity of the instrument. Understanding this is critical to HUD proficiency.

Having said that, any experienced HUD pilot will know this, because they will have used the HUD during a many a turbulent approach to land, and learned not to over-control accordingly. They will also know that if they are not liking the HUD then they will automatically go eyes-to-the-PFD.

The aircraft involved in this accident was probably experiencing turbulence and maybe windshear. However, I personally can't conceive that HUD over-controlling was in any way a contributing factor to this accident. All the same, I just thought I'd end my HUD explanation with an honest and unbiased appraisal of the pros and cons of the instrument, and to point out again that training and experience is necessary to use a HUD.

[Alycidon]

Derfred, thanks again, to us non HGS equipped, this helps to understand why the HUD is a useful aid to safe flightpath management.

Vortex, sorry to have speculated about the use of the HGS without fully understanding the system, but according to the MAK interim report, there was a 12s APND trim input and we now know from Derfred that the HGS can be difficult to interpret in turbulence.

On the 737, the windshear escape manoeuvre, (after performing initial actions such as maximum thrust, 15deg pitch) recommends following useful guidance. On the HUD, the F/D (or guidance cue as it is known in theF/D guidance - because the F/D has a "windshear mode" which gives very HUD world) appears to dash all over the screen - as it responds immediately to every turbulent aircraft pitch and yaw - to the point where attempting to follow it appears to become an exercise in futility.

I said as much to the instructor after the event, having concluded already that I basically had no control over the aircraft using the HUD. He then asked the F/O what he thought of my efforts. The response was "extremely well handled". According to his PFD, I was flying the F/D very accurately, and the whole manoeuvre was very well flown

The RHS cannot use the HGS and the guidance is more sensitive than the PFD, so we have one pilot using one type of guidance system and the other pilot using a different one.

So, from your information regarding the HGS, is it not possible that a dual and opposing control input was the cause of the 12s nose down trim input, bearing in mind the crew must have been tired and somewhat stressed.

What would your views be on the cross cockpit co-ordination when both pilots are using different displays? The interim report does not mention whether the HUD was in use or not, but it would seem from the thread that it is SOP.

It also seems that the HUD/FGS requires a degree of currency, is it used for all approaches or just for LVOs?

The 737NG HUD is designed to be used in all phases of flight. It reduces the instrument scan rate required during manual flight and generally results in much more accurate manual flight - including a go-around or windshear escape.


In this case it didn't.


Thanks again for the informed comment.

[Chronus]

Derfred`s comments are most informative on the HUD. As the inferences drawn from known facts seem to point towards energy mismanagement, in the event the crew were reliant on HUD during the approach, would it not be reasonable to assume the HGS would have provided enhanced SA and energy management and would have alerted the crew from excessive and ill timed nose down pitch trim.

[MATELO]

737 HUD landing

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

[CHfour]

Waaayyy too much information for my old brain to process. I think I'll stick to my PFD and looking out of the window when it's nice and let George do the landing when its foggy.

[xollob]

that hud video is interesting, not much in the way of brown/blue though, 50 degrees nose down on a PFD would show a lot of brown, on the hud is there just a horizontal line for the horizon and no obvious colour pictorial ?

what's it like for unusual attitude recovery ?

[Chronus]

Bearing in mind we are talking about civil transport aircraft, if you mean brown on top and blue on bottom, some place like inside the marker on approach, then I`d guess it ain`t gone be much use.
Even in high performance combat aircraft ADI reference is a better guarantee against SD.
Here is some info on research conducted on the subject of HUD v Back up display in a static F18 sim.

http://www.lw.admin.ch/internet/luftwaffe/en/home/dienstleistungen/amc/publikationen.parsys.0001.downloadList.00011.DownloadFile.tm p/recoveryhudvs.con.pdf

[recceguy]

Well, after reading all those posts of "experts" ... my input would be that it's quite difficult to say : HUD will do that, will induce those problems .... and PFD by the contrary ...
simply because it all depends of the MODEL of HUD you have, and the associated symbols displayed in it.
I've been flying HUD since 1984, a very advanced one which was changing a difficult aircraft into an easy one - simply because it was, and is still the best on the market. I flew after maybe 15 or 20 different ones, some of them really poor (horizon ? energy brackets ? FPV looking as a FPV when it simply was not...) Also the fact that the industry and the manufacturer can put anything they want in a HUD - well, in fact anything the test pilots want, and even the line pilots want. I have seen such ridiculous solutions "in order to prevent pilot disorientation" ....
Suffice to say that with a good HUD, you can make a barrel roll at low altitude in poor weather and horizon conditions, where you would have been killing yourself with the same aircraft without the HUD (yes, some had, and some hadn't)

Same for a HUD as for a head-down cockpit instrument : a nice one (russian, french often) will be a tremendous advantage, which will make you the pilot say "waoww.." when a poor design - such as some AOA indicators from anglo-saxon world - will make you move away from the stuff, with the assorted wrong conclusions. Did you know by example that you can find on the market HDI combined with HSI ?

When I became an airline pilot, I was so disappointed by how those aircraft were backwards. Then came, eventually and slowly, HUD for transport aircraft - and once again, some great, and some utterly complicated. Anyway, in cruise for hours they have nothing else to do than looking at it, and the approaches are always linear and simple, so I guess after some time they become familiar with the design, no matter how cluttered it might be..
So Derfred, sorry, your comment was about ONE type of HUD, not all the HUDs in general.

[framer]

Surely no pilot could ever do
a barrel roll at low altitude in poor weather and horizon conditions
To do that one would have to be an amazing pilot, one of the best there ever was. :rolleyes:

[DOVES]

Chronus wrote:

An important aspect of the CVR analysis will no doubt involve the differing nationalities of the flight crew. The captain, a Greek Cypriot and the FO a Spaniard. Therefore English not their mother tongue. Add to this Russian ATC. Might bring into question issues concerning communications, particularly at critical times. It is not always what is said but how it is said that may affect outcomes.

AND:

- Call sign: Fly Dubai 981
- QFE 981
- 'Cleared 900 meters height'
- QNH 998

AND:

- Following HUD indications
- Landing Lights ext/ON in clouds

Is there any reasion for confusion?
More clearly than that?
It 's like a mute who wants to lead a blind in a forest.

[porterhouse]

when a poor design - such as some AOA indicators from anglo-saxon world
Disagree - AOA should always be there, specially in view of whole recent slew of accidents where AOA were busted. You don't want to watch AOA - fine, it occupies probably less than 2% of HUD display.

[Linktrained]

With ( only ) "a 1 hour 20 minute Hold", JFK sent us and other aircraft to do a "60 mile Hold at Nantucket" which was much more relaxed than a smaller holding orbit would have been. ( We had no Auto Hold facility on the A/P.)

Whether something rather like this could have been an option offered by ATC at Rostov...at the time, is a different matter.


( PS we had had prior indications of of possible delays at JFK and had taken additional fuel - amount now forgotten. After close down,we had 3900 kg. remaining. We would have needed 4052 kg. for a full 2 hour Island Holding.)

[RAT 5]

A lengthened hold is something I've used many times and ATC were very helpful in allowing it. It proved useful one time when approaching destination with not a lot of extra, but a faint chance of getting in as the back log of traffic at destination dissipated. Our Altn was 80nm away. We arranged a hold at 30nm FL 100 from destination with 20nm legs towards Altn. Just before turning inbound we checked if we could expect an approach next time over the fix. No was the reply so we were well paced for an 'on-path' descent into Altn.
The reduced amount of turning makes the whole exercise more relaxing as well.

[recceguy]

Porter house : I wrote "some AOA indicators of poor design" and you understood "ALL AOA indicators" Sorry for you.

Framer : also at night over the ocean starting from 500 ft, if you want - aircraft used in the Falklands war.

[Vortex Thing]

Recce guy. It would be helpful it you just told us the type of aircraft you are referring to instead of making us guess. If you don't want to tell us then don't make the reference!

Half information is sometimes worse than no information.

Doves. Yes what chronus wrote is all perfect normal to anyone used to flying into Russia. at FZ we had 18 destinations in Russia and CIS so it was an every day business to be in metres and QFE and QNH none of this would have been confusing to a crew used to operating there.

Framer you frequently make comments that show you have only operated in certain climes. Ie in a another thread, "is it standard phraseology to say FL two hundred anywhere" If you had ever flown in UK and much or Europe you would wonder if exact opposite was true.

Re this thread a barrel roll at low altitude in poor weather and horizon conditions.

In military flying hardly a surprising or unusual event (depending on ones definition of low level!)

When I started operating into the US I found some things so different from the rest of the world that I hit another point in my career of realising how much more there is to learn.

Surely the whole point of these forums is so that we help each other understand the environs and situations that we all fly in can be very very different. My first few flights into the US were like flying into alien territory. The whole language, meaning and interpretation is vastly different to anything I had encountered in years of flying in Europe, Middle East, Africa and Asia. So much so that it was the comprehensive briefing from the trg cast as we went transatlantic that prepared me for my first arrival into US airspace since the late 90s and it was staggeringly different.

The point is some of us like myself and Derfred fly on HUDs every day. Some don't and some fly B737 where there is only one HUD. Some guys fly polar, some transpacific and trans atlantic, some guys are flying BE1900 mail runs in UK. So each of us has a lot to learn from the other until we get to place where we have done it all!!

Can't we all stop scoffing at how ridiculous the former posters view is and ask questions.

Perhaps we could as professional pilots to each other say. Oooh I didn't realise that was standard in part of the world X can anyone who operates that type/region/piece of equipment clarify please?

[framer]

Framer you frequently make comments that show you have only operated in certain climes. Ie in a another thread,
Quote:
"is it standard phraseology to say FL two hundred anywhere"
Yes......and? I don't get your point Vortex. In one breath you make the above comment then in the next you say we should all try and learn off each other. The reason I ask questions like that is because I am interested to learn and I don't mind if people can figure out that I have only operated in 'certain climes'.
Perhaps we could as professional pilots to each other say. Oooh I didn't realise that was standard in part of the world X can anyone who operates that type/region/piece of equipment clarify please? That's pretty much what I was doing by asking the question. Anyway, let's try to get back on topic, has anyone noticed that the Cof G was unusually far fwd at dispatch? I wonder if Flydubai allocates seats, anyone know?

[Avenger]

Apart from the CRM aspect and general decision making, which is speculation until the "allowed elements" of the CVR are released, the rest is simple physics and energy management. With the flaps out forward trim for 12 seconds takes the trim well beyond the green arc, couple this with a reduction in the pitch power couple as thrust is reduced, the aircraft is only going one way... down.. increasing power after the aircraft tips forward or pulling back, as they did only deepens the dive... try it in the sim.. we just did..trimming back to a neutral position and then correct thrust management allows a recovery, but not from the altitude these guys had remaining.. doesn't matter if you look through HUD, FD or ski goggles its just a mistake, and we are all human..

[Alycidon]

doesn't matter if you look through HUD, FD or ski goggles its just a mistake, and we are all human..

I think you are missing the point.

[Avenger]

Exactly what point would that be then?

[Sandlandman]

Yes you get allocated seats on FZ. But on such a light flight everyone will have moved around so there would only be one or two people per row of three. Crew usually allow this after all pax onboard.

[Alycidon]

This point:With the flaps out forward trim for 12 seconds takes the trim well beyond the green arc,

It's pretty obvious the aircraft will be uncontrollable if 12s of APND trim is applied, the question is why was the ND trim applied for so long?

I have suggested that somatogravic illusion, coupled with the visual cues of clouds, highlighted by the landing lights, seen through the HGS display may be the traps leading to the impression of a false pitch up, with tiredness or fatigue, leading to the confirmation bias that the aircraft was pitching up when in fact it wasn't.

The first go round was, I believe due to windshear and I'm assuming from the advice from derfred that the PFD would be the main source of guidance in windshear due to the FD being active for windshear escape, eliminating the distraction caused by the visual picture.

The second go round, from the MAK report, was not due to windshear, but due to stable approach criteria not being met and therefore the HGS would be the primary source of guidance, not the PFD.

[Vortex Thing]

Framer my point is how you said what you said. Not what you said. I willingly accept that you can read it in any way. However the problem with making statements that cannot be differentiated from questions is that someone (on this occasion me) will likely see it in a way that perhaps you intended perhaps you didn't.

i.e. It is the difference between:

Helping Uncle Jack off his horse.
and
Helping uncle jack off his horse!!

I read what you wrote as hands thrown up in air that something so spectacularly unusual could ever be normal. When it is abundantly clear that not only is it normal, it would actually make sense to make it the norm worldwide and then there would be far far less level busts.

If every controller and pilot only used one, two, three, four and five hundred in respect to levels just think how many less level busts there would be with 100,110,120, 200,210,220 etc. Not only that what other loss of seperation events would be avoided.

The one thing I have noticed since I started operating into the US is how often there are confusions about what someone is meant to do next. i.e Do I descend now or at pilots discretion? Any particular rate, oh well you haven't mentioned one I'll just do X or Y and then being told to descend faster or slower. This constantly seems to need clarification, reread backs and seems chaotic in comparison to approaches into airspace like London TMA for LHR or LGW where there seems very little chaos regardless of the weather or scenario on the ground.

I can't find where it says, "climbing out of four point oh for nine thousand". ICAO Doc 9432, it certainly isn't in CAP371 (understand this is a UK doc) I am sure it is likely in some FAA doc somewhere however only the US pilots seem to use it. I'm English and to me this is just gash RT. However for the poor pilots speaking English as a 2nd or 3rd language then you are asking for trouble in the form of loss of separation and/or level busts.


Back on Thread
However as you suggested, now we both know what we meant the point of the thread is the accident. Re the FWD CG. At FZ we did zone pax but it was very very rarely used for boarding as to be honest organising FZ pax is like hearding cats.

If everyone did what they were supposed to then every pax should be sitting in the seat on their boarding pass and the CG on the LIR and load sheet would reconcile. If we got LMCs we would normally ask where the pax/s was/were sitting to make sure we did not need a new loadsheet for that very reason.

However this was crew dependant. As no one really cared about standardisation and things like this were a rarely checked and b) if checked online or even in the sim were done by TRE/TRI/LTCs who were working to their own agenda (because they never got the chance to standardise as no time or direction was ever made available N.B. not blaming the instructors for this)

SO it would depend on how diligent the crew were. I always blocked off seats/ asked for changes in rows or moved pax to make the CG work if they weren't where they meant to be or on the occasions when we had free seating (certain routes and charters)

To this end if we assume they followed the procedures as they are written. The FWD CG on departure would likely have been as they had full wings AND full ctr tank. They would have expected to burn the ctr tank enroute and in the hold given that they knew they were unlikely to land on arrival and this would have of course led to progressively rearwards moving CG as the flight continued.

Not particularly relevant in this case but it is in FZ ops, business class has very few seats and if it is not full and economy is because we didn't really distribute loads to each flight (more a set plan out of Dubai) it meant that the rear hold would be full and the front empty of vice versa i.e it was never something that was done as sensibly in some airlines where they would try and achieve a certain MAC% as that was the most efficient for route X. We weren't even allowed to enter the cruise MAC in the FMC!

Also what you said in post 9362192 was spot on. The culture is that punitive that you simply didn't divert until you HAD to fuel wise to save nugatory discussions with the chief pilot or his cronies who couldn't give a stuff about anything other than getting the plane back for the next sector!

Alycidon

I think you are misinterpreting what Derf said and/or meant. From my perspective (I leave derf to concur or not) using the HGS is more natural than anything else. Whatever is happening outside does not confuse you you just say with the guidance. You will be surprised how intuitive it is. After flying with it for a bit I now would hate to be without it there is no situation where I glance down at the PFD unless the guidance fails. You don't get distracted by the outside picture you just focus your eyes on the display and the outside picture disappears. Coming into land you frequently have to keep turning down the brightness to see the outside world and runway.

Granted there could have been a problem of a newish skipper on the HUD not trusting it and likely not having seen the UA or W/S symbology as it changed to non conformal other than in the sim but I do not think illusions were the issue here, somatogravic or otherwise. I think the whole thing put together with fatigue put on top simply led to a mistake which wasn't noticed until it was too late to do anything about it for the poor souls. I'm sure something else didn't help them but chances are it was all of the things in combination (isn't it always).

[glad rag]

How easy is it and how often is instrument cross checking required??

[OK465]

and likely not having seen the UA or W/S symbology as it changed to non conformal other than in the sim

Indeed.

When the actual flight path is below the HUD FOV, i.e. performance decrease W/S situation, with pitch attitudes within the conformal range (normal non UA display), the FPV remains visible at the very bottom of the HUD FOV and is 'ghosted', i.e. a dashed line symbol. The 'solid' HUD W/S steering ball still provides W/S guidance relative to the ghosted FPV.

I have observed various levels of confusion in this situation even with reasonably experienced HUD drivers. These transitions out of and back into the normal day-to-day conformal display require some degree of practice. PFD is the fallback.

[Alycidon]

cheers vortex, I don't use the HUD so am naturally suspicious, the 12 s ND trim is unfathomable but I just feel that somehow the PFD leaves you more in touch with the aircraft and less fixated on the guidance and outside picture.

Using the PFD, your attention would be drawn toward the inside, including the position of the flight controls and you would probably see the trim wheel in motion, whereas using the HUD your attention is drawn towards the visual picture, surely that's the point of it.

[RAT 5]

Simple question from the great ignorant: which is easier IMC/night, PFD HUD?

[framer]

That depends on the individual, some people love it and use it all the time, others use it in some circumstances and I even know a couple who never fold it down.

[olasek]

which is easier IMC/night, PFD HUD?
Perhaps it is really a wrong question - you should be watching what it is easier for you. I suppose if I have no chance of seeing ground anytime soon why would I be watching HUD at all?

[framer]

I use the HUD from the start of the take-off roll until about 20,000ft. I then fold it away but sometimes bring it down again in the cruise approaching weather. Most of the time it is away until about FL150 on descent then I bring it out again regardless of IMC/night/ day etc.
I find it good for finessing but use the PFD for 'gross' changes. I do about one landing a month without it normally due to turbulence ( personally I don't like it when it's rough). That's just me though, everyone I speak to uses it in a different way , it's just another tool to be used. Personally I'd be surprised if the HUD had any impact on the outcome of this flight and personally I'm on the PFD for the GA until levelling out.
All of the above is to show that different pilots use it in different ways.

[iflyboeing747]

None of us were there, so it's hard to judge.

[framer]

Plenty of us have been in similar situations and know how our performance levels decline when we are completely stuffed though.

[RAT 5]

I suppose if I have no chance of seeing ground anytime soon why would I be watching HUD at all?

I have no experience of a HUD, but this aspect was behind my question. If you can not 'look through' the HUD to your target is it that useful, or are even the symbols that clear? If the HUD's background is cloud or landing light glare-back is it the best option?

[framer]

Beautifully clear, easy to see at night, imc or day VMC , it doesn't matter.

[Icarus2001]

How easy is it and how often is instrument cross checking required?? Which instrument(s)?

[Yaw String]

Framer...lets hope more of us will recognise challenges,greater than we are able to safely cope with,for ourselves,and for the sake of the passengers nerves...
I infer no criticism of this particular crew.......

[framer]

Let's hope that.
It is a shame when the safety levels of an entire global industry with an amazing safety record are being eroded by shoddy rostering practices that don't consider circadian rhythm and we simply 'hope' that pilots will recognise when their performance capabilities are reduced to an unacceptable level.
This type of rostering is becoming more and more common and is making its way into all corners of the globe. In thirty years time when we have effective methods of assessing an individual's performance capabilities quickly and easily we will look back on a lot of these 'pilot error' crashes and say "No wonder the crew made a mistake, the industry was pretty naieve back in the early 2000's."

[Sciolistes]

Indeed Framer.

Lucky dip rostering is the new FRMS. FRMS is, through the front door, a way of formalising a crew member's individual responsibility to declare themselves unfit. Woe betide anybody who calls in fatigued without a detailed log of their activities and sleep for the last two weeks.

[captplaystation]

Am I the only one raising an eyebrow as to why no interim report has emerged, don't suppose Uncle Sam would try & hide a trim runaway whilst working out how best to make scapegoats of the crew.

[Chronus]

No you are not alone, add me to the list. Short of being complete bonkers,I simply cannot conceive how totally zonked out the crew needed to be, to have attempted such a stunt, which even a complete imbecile would find it hard to achieve. Moreover what are the chances of having a matching pair of such imbeciles ensconced together at the same place, at the same time.

[Ian W]

About the same as on AF447? But AF447 managed a prile.

[JammedStab]

Am I the only one raising an eyebrow as to why no interim report has emerged, don't suppose Uncle Sam would try & hide a trim runaway whilst working out how best to make scapegoats of the crew.
Yes that's it, Uncle Sam is trying to hide the truth.

You and the following poster are at the genius level....not.

[G SXTY]

I simply cannot conceive how totally zonked out the crew needed to be, to have attempted such a stunt, which even a complete imbecile would find it hard to achieve. Moreover what are the chances of having a matching pair of such imbeciles ensconced together at the same place, at the same time.

I assume you've not worked for Flydubai then?

I have.

And I've had rosters just like the FO's, and I've sat there at stupid o'clock in the middle of the night, "totally zonked out", with absolutely no capacity to deal with anything untoward - I couldn't even read back our callsign, never mind cope with a non-normal. I was just lucky that (a) nothing went wrong, and (b) the other guy was sharper than me.

It ain't a conspiracy and it ain't rocket science - run an operation where fatigue is rife, keep sending knackered pilots up night after night, and sooner or later you'll have a smoking hole in the ground.

Unless you've been there, it's difficult to appreciate just how bad it is.

[Chronus]

Thankfully I have not, ever. But accepting your word, my words to describe such practices would be callous disregard to everything we believe, know and accept as safety. Yes you were lucky, but so were all those innocents sitting behind you in complete ignorance of the state of affairs up at the front end. Sort of thing nightmares are made of.
The only way to put a stop to this sort of practice is to put the guy who is at the very top of the food chain behind bars, and to do so not after a catastrophic tragedy, but way before, when a whistle blower with the full weight and authority of the law and without any fear of loss of his meal voucher, can stand up in a court of law and point the finger in the right direction.
Regrettably, even if this may have been the case in this instance, there could be no way to prove it, as they say beyond a shadow of a doubt. Those poor fellas have zonked out permanently.

[Chesty Morgan]

Or just call in fatigued as we are legally and morally obliged to do.

[QDM360]

Am I the only one raising an eyebrow as to why no interim report has emerged...
The interim report was published 4 weeks after the accident:
http://mak-iac.org/upload/iblock/310/Interim%20Report%20A6-FDN%20%28en%29.pdf

[Vortex Thing]

The problem of course is that if you call in fatigued when you work for a firm that has neither moral compass or legal viewpoints in the entire management team you endanger your career, your livelihood, your future and possibly your liberty.

I fear you do not quite understand how morally reprehensible the chief pilot and his direct report actually are.

They don't care if what you do is morally or legally correct know you just do it or end up on their radar. They simply don't care!

Your choices remain simple do as you are rostered, asked, told or face schoolyard tactics with the ante upped!

I personally voted with my feet. Best career move to date!

[Chesty Morgan]

Well, whatever you endanger by calling in fatigued is still endangered if you don't. The difference being you might still be alive if you do.

[RAT 5]

Grounded a/c are the only things these types understand. What has amazed me over the years is how these types of managers float around the world popping up in new start ups who need "candidates with previous experience and proven track record." If their background check was subjected to half what a pilot applicant's is I wonder how many would be able to continue their style of management as a globe-trotting Dracula. Employee morale does not seem to appear on any manger's job description.

[olster]

The 'manager' dimension has not changed since the very beginning. A bigger set of arrogant clowns it would be hard to find. Unfortunately, they contributed one part of the swiss cheese and this should be acknowledged. They take the ME dynamic of self centred personal agenda to a new level. Hopefully, karma will have its way inshallah.

[captplaystation]

QDM360, yes sorry, I had read that, but was expecting some more info as to the whys & hows they thought the stab trim would run for 12 seconds (having sat & timed it, I cannot fathom any current B738 driver sitting with his thumb on the pickle switch for that length of time) & was hoping maybe an update with more CVR/FDR input.

[Hotel Tango]

I cannot fathom any current B738 driver sitting with his thumb on the pickle switch for that length of time

And even the CVR/FDR will most likely not answer that very pertinent question. 12 seconds is a very long time!

[Centaurus]

I cannot fathom any current B738 driver sitting with his thumb on the pickle switch for that length of time

I have seen this happen in the simulator on a few occasions. Always during a go-around where the natural pitch up on application of GA thrust is not contained immediately. Usually this happens in IMC where no visible horizon is available to see not only the rate of pitch up but how much above the horizon. In other words poor instrument scan.

Instead of using immediate strong elevator force coupled with careful forward blips to the stab trim to contain the pitch up, the pilot uses the stabiliser trim switch in a continuous motion and keeps his thumb on the switch waiting for a reaction. 12 seconds is a long time to wait for the nose to lower and by then it goes nose down rapidly and no hope of recovery at low altitude on instruments.

It all boils down to poor instrument flying manual skills. Blame lack of proper simulator training in the manoeuvre in terms of manual go-around procedures. Auto go-arounds are a non-event. Manual go-arounds are another story altogether especially on instruments

[framer]

Well if you're so stuffed that your brain is not coping with the info it is presented with, who says it won't 'stall' for twelve seconds?

[henra]

Instead of using immediate strong elevator force coupled with careful forward blips to the stab trim to contain the pitch up, the pilot uses the stabiliser trim switch in a continuous motion and keeps his thumb on the switch waiting for a reaction. 12 seconds is a long time to wait for the nose to lower and by then it goes nose down rapidly and no hope of recovery at low altitude on instruments.


From all we know this description seems to hit the nail on the head.
Unfortunately the pure readings from CVR/FDR will not be able to finally and undoubtedly confirm this 'why'. It should at least hopefully be able to distinguish if it was an uncommanded trim runaway or a commanded action. If it was the latter, your description is probably as good as it gets.

[JammedStab]

QDM360, yes sorry, I had read that, but was expecting some more info as to the whys & hows they thought the stab trim would run for 12 seconds (having sat & timed it, I cannot fathom any current B738 driver sitting with his thumb on the pickle switch for that length of time) & was hoping maybe an update with more CVR/FDR input.
You already told us. It is Uncle Sam covering it up. Now, if you want some well thought out reasoning, read again this quote from a few later posts:

"I have seen this happen in the simulator on a few occasions. Always during a go-around where the natural pitch up on application of GA thrust is not contained immediately. Usually this happens in IMC where no visible horizon is available to see not only the rate of pitch up but how much above the horizon. In other words poor instrument scan.

Instead of using immediate strong elevator force coupled with careful forward blips to the stab trim to contain the pitch up, the pilot uses the stabiliser trim switch in a continuous motion and keeps his thumb on the switch waiting for a reaction. 12 seconds is a long time to wait for the nose to lower and by then it goes nose down rapidly and no hope of recovery at low altitude on instruments.

It all boils down to poor instrument flying manual skills. Blame lack of proper simulator training in the manoeuvre in terms of manual go-around procedures. Auto go-arounds are a non-event. Manual go-arounds are another story altogether especially on instruments"

Seems more logical, wouldn't you think.

[sansmoteur]

Very plausible, Centaurus.

[Chronus]

Adding my vote to Centaurus leaves only the following questions. Why the change of mind from going up to going back down or levelling. It has been said turbulence may have been the cause. How severe could it have been, as bad as eye ball shaking - white knuckle grip- thumb frozen on pickle switch type?

[AtomKraft]

I've got 12500 hours in regional ops.

Never flown less than these days,

I often think, as I walk out to the plane, 'am I actually a pilot?'

A I going to fly this thing?

My manual flying skills- which I think are of a decent order, and which I try my best to maintain, seem to be a small part of the skillset needed.......

More prominent things- things featuring in many thoughts before flying skills are.....

1. How am I with the management? Do they think I'm ok? Or are those HR people going to get me?
2. How am I with rostering? God, If only I could get the flights and roster that I want.
3. Will my girlfriend be ok with me going away for five days....?

Bloody hell. Flying the plane is the least of my worries...

[klunk49]

I agree with Centaurus, push in to much thrust, pitch up, get wind gust adding to light weight,you are climbing for a high altitude set in MCP,forget to delete altitude restriction in FMS, FD suddenly says pitch down NOW! Snatch the thrust levers off, pickle trim down, in attempt to return to FMS altitude, trim motor moves HS quickly in flaps 15 position,not looking through FD,tired, brain fart! Went from +20 to -15 pitch, now with HS pitch in -4 degree nose down position, try to recover by only pulling on elevator, won't work. Swiss cheese model accident compounded by tired crew. Lots of "should have,could have, would have" in this accident, lets all learn something from it. The airplane was just along for the ride, nothing wrong with it....Well said AtomKraft!

[Flying Clog]

Bloody hell, that's scary klunk49

[RAT 5]

you are climbing for a high altitude set in MCP,forget to delete altitude restriction in FMS, FD suddenly says pitch down NOW!

Will that happen in TOGA? Is it not the case that MCP ALT controls in TOGA & LVL CHG and FMC ALT controls in VNAV?

[16024]

Is it not the case that MCP ALT controls in TOGA & LVL CHG and FMC ALT controls in VNAV?
Yes.
But only if the MCP ALT is above the point where you engage TOGA. If you forget to set the GA ALT in the MCP (having maybe set a lower MCP ALT to avoid ALT ACQ) it will climb till it runs out of petrol.
If at some point you realise and hit LVL CHG (especially if the MCP speed is high) it will hurry towards the ground.

[Chesty Morgan]

No, it'll head towards whatever altitude you have set when you press TOGA. It won't automatically climb!

[de facto]

click click,,magic

[16024]

It won't automatically climb!
It won't "automatically" climb unless you are dual channel and Flare Arm. But provided TOGA is armed (and there's no way of telling) you'll get 15 degrees pitch UP, and if the A/T is in you'll get a handful of thrust.
Surely (Shirley?) you're not saying if I am at 2100 feet on the Glide with 2000 M/A set its going to go down in TOGA.

[Centaurus]

Bloody hell, that's scary klunk49

So is blindly following a flight director into the deck:ugh:

[RAT 5]

True; I was forgetting they initiated TOGA quite early, i.e. well above MDA. However, they had briefed and requested FL80, and the PF had asked on approach if the MCP had been set. It would have been either 3000' or 8000. Either way above the TOGA altitude???

So is blindly following a flight director into the deck

I have seen in the sim, cadets under stress as they all are, on an ILS at DA the application of GA power without pressing TOGA and continue down the GP at accelerating speed. FLT FRZ and discuss. Both for PM & PF.

[Chesty Morgan]

It won't "automatically" climb unless you are dual channel and Flare Arm. But provided TOGA is armed (and there's no way of telling) you'll get 15 degrees pitch UP, and if the A/T is in you'll get a handful of thrust.
Surely (Shirley?) you're not saying if I am at 2100 feet on the Glide with 2000 M/A set its going to go down in TOGA.

No, my bad, I didn't read your post properly (blame a Borolo induced hangover). GAs at heights above TOGA activation have seen recent discussion at our place and the importance of setting the MAA first if you're using Level Change. We've got a handful of aircraft where TOGA activates above 2000' but most don't.

[16024]

We've got a handful of aircraft where TOGA activates above 2000' but most don't.
Yep, the 737 options list must be like a phone book.
"It's like a box of chocolates..."

[RAT 5]

Except with such a box of chocolates I often close my eyes to be surprised. You don't know what you're getting. NOT recommended on an a/c.

[FGD135]

I cannot fathom any current B738 driver sitting with his thumb on the pickle switch for that length of time
Very easy to fathom.

The pilot presses the switch, and leaves it pressed, knowing that he is going to have to leave it pressed for a good 5 seconds or so.

But, approaching the 5 second mark, he gets distracted. This was about the time the aircraft was levelled off, so the need to manage the flight path would have provided several challenges that would easily be enough to distract a tired pilot.

Was there a radio exchange at around this time? If so, that could also have served as the distraction.

Being distracted, his thumb just remains on the switch ...

I bet Boeing will modify the trim logic so that the trim can only be run for a maximum of a few seconds at a time.