Boeing incidents/accidents due to Thrust/Pitch mode mishandling

[Smooth Airperator]

Hi all,

Can anyone help me with Boeing (regardless of type) incidents that have been caused because the crew did not understand or use Thrust and Pitch modes correctly or if Thrust and Pitch mode was a related cause. From the top of my head:

-Asiana 777 SFO
-Turkish 737 AMS
-FlyDubai 737 RVI
-EK 777 Dubai

Thanks

[Intruder]

The mishap report for Asiana at SFO is available. The Captain grossly mismanaged the autopilot modes, making several changes in rapid succession on final approach. Even after the 3rd pilot in the observer seat warned him twice, he did not correct. IMO, that was COMPLETELY pilot error.

[A37575]

The easy way is to Google your request or Google each of the accidents you stated. There have been countless incidents/accidents of this sort. In almost every case the direct cause of the accident/ incident boiled down to the fact that the pilot was automation addicted and lacked basic instrument flying ability. Some may say that is a long bow to draw. Others may have the opinion that the pilot simply didn't know how to fly - a well established result of automation dependency..

[KRviator]

Hi all,

Can anyone help me with Boeing (regardless of type) incidents that have been caused because the crew did not understand or use Thrust and Pitch modes correctly or if Thrust and Pitch mode was a related cause. From the top of my head:

-Asiana 777 SFO
-Turkish 737 AMS
-FlyDubai 737 RVI
-EK 777 Dubai

ThanksI wouldn't entirely classify the Amsterdam 737 accident as the crews fault. The primary cause was a faulty radar altimeter that provided an erroneous signal to the autothrottle that retarded the thrust levers. The crew manually advanced the thrust levers, but because he didn't disengage the autothrottle, the computer again retarded the thrust levers.

You could also include China Airlines 006 in that, after an engine rollback, they failed to monitor their airspeed, resulting an a departure from controlled flight. Again, an underlying issue occurred, mode confusion was not the primary reason.

[stilton]

I wouldn't entirely classify the Amsterdam 737 accident as the crews fault. The primary cause was a faulty radar altimeter that provided an erroneous signal to the autothrottle that retarded the thrust levers. The crew manually advanced the thrust levers, but because he didn't disengage the autothrottle, the computer again retarded the thrust levers.

You could also include China Airlines 006 in that, after an engine rollback, they failed to monitor their airspeed, resulting an a departure from controlled flight. Again, an underlying issue occurred, mode confusion was not the primary reason.



Pretty incredible you’d blame the AMS
crash on anything other than pilot error


If you’re so clueless you don’t recognize
airspeed decreasing without an appropriate
response from The autothrottles, then take over and correct you are incompetent, a passenger not a pilot


Funny, we flew aircraft for decades without
AT, how did we survive?

[hans brinker]

I wouldn't entirely classify the Amsterdam 737 accident as the crews fault. The primary cause was a faulty radar altimeter that provided an erroneous signal to the autothrottle that retarded the thrust levers. The crew manually advanced the thrust levers, but because he didn't disengage the autothrottle, the computer again retarded the thrust levers.

You could also include China Airlines 006 in that, after an engine rollback, they failed to monitor their airspeed, resulting an a departure from controlled flight. Again, an underlying issue occurred, mode confusion was not the primary reason.

I disagree. The only reason we still have pilots is for when **** hits the fan, anything else can be automated. The radar altimeter failed and that led to the auto thrust to go to idle. The FO pushed the throttle up, let go, it went back to idle, and for the next 100 seconds all 3 of them sat there while the thrust was at idle, and the speed dropped to 83kts, 40kts below Vref.

Same for the China airlines flight. They just sat there, never used rudder trim, let the speed drop until the autopilot gave up, and barely made it out alive.

If we can’t handle stuff like this we don’t deserve to get paid to fly.

[Dan Winterland]

Accident investigation has tended to move away from finding a 'root' or single cause as being responsible for an accident. Also, the practice of finding fault with the operator is also less prominent. People don't go out to deliberately make mistakes. In the 'pilot error' cases mentioned above, the modern accident investigator will look to why the pilots followed the actions they did. If they are as a result of not fully understanding the system, they will look at training/and or manuals. A good example of this, and another case for your study is the B737 serious incident at Bournemouth in 2007 https://www.gov.uk/aaib-reports/aar-3-2009-boeing-737-3q8-g-thof-23-september-2007

The B737 accident at RVI has not yet had it's report published. Although the pitch/power couple with applying full power at a low speed is probably going to be considered a factor, I would strongly suspect that spatial disorientation will feature more.

[172_driver]

https://en.m.wikipedia.org/wiki/Tatarstan_Airlines_Flight_363

Tartastan 363 in 2013.

[KRviator]

Pretty incredible you’d blame the AMS crash on anything other than pilot error

If you’re so clueless you don’t recognize airspeed decreasing without an appropriate response from The autothrottles, then take over and correct you are incompetent, a passenger not a pilot

Funny, we flew aircraft for decades without AT, how did we survive?
I disagree. The only reason we still have pilots is for when **** hits the fan, anything else can be automated. The radar altimeter failed and that led to the auto thrust to go to idle. The FO pushed the throttle up, let go, it went back to idle, and for the next 100 seconds all 3 of them sat there while the thrust was at idle, and the speed dropped to 83kts, 40kts below Vref.

Same for the China airlines flight. They just sat there, never used rudder trim, let the speed drop until the autopilot gave up, and barely made it out alive.

If we can’t handle stuff like this we don’t deserve to get paid to fly.Respectfully, I think you've both missed the point. I guess you would both argue that AF447 was solely the result of the crew, rather than the fact they lost the airspeed in the first place...

Yes, the crew screwed up (in both AMS and AF447...), in a massive way. I am not disputing that fact at all, nor trying to absolve them of that claim.

But...

Amsterdam was not, in itself, the fault of mode confusion, or automation dependency. The crew recognised the decaying speed, and that the throttles retarded automatically. They then pushed them up, and believed (and this is where their lack of systems understanding failed them) they would stay there - and through lack of basic airmanship, let the speed decay to a point where the accident was inevitable.

Consider the case of Scandinavian 751. Engine surge on the initial climb, pilot does the right thing and reduces power. But the autothrottle restored power on the engine, resulting in dual engine failure and the ensuing crash. The pilot knew nothing about that 'feature', nor did the airline. Is it still their fault for not noticing the increasing power? The moral of the story is, pilots screwup certainly. But rarely does that, in itself, cause an accident and it is fatally simplistic to simply lay the blame for a prang at the feet of the crew.

[A37575]

(and this is where their lack of systems understanding failed them
You could apply that concept to practically every aircraft accident. In another words avoid hurting the pilots feelings by saying it is never his fault. It is the fault of the designer. if a student pilot stuffs his round-out in his Tiger Moth and bends the propeller the fault is whoever wrote the Tiger Moth Pilots manual for omitting the vital fact that pushing forward on the stick in this design of aircraft can cause the nose to dig in.

Once upon a time we took responsibility for our own actions. In other words we stuffed up by over-controlling during on the flare, or left the power on for too long and floated off the end of the runway. Now we see the tendency to get out of trouble by blaming everything else except ourselves. The Amsterdam crash was a massive pilot cock-up from the time the autothrottles closed during final to the final impact. It was nothing to do with lack of systems knowledge.

One theory came from a first officer of that airline and that was ethnic culture played a significant role in that accident. The cockpit gradient with the former military trained captain was so steep that neither of the two officers would have dared to take decisive action to prevent the accident lest they caused loss of face to the captain. The operative word being decisive.

[Capn Bloggs]

You old codgers can rant and rave all you like. The concept that a perfectly serviceable autothrottle system would just stay asleep when the speed was 30 knots below Vref is ludicrous.

One theory came from a first officer of that airline and that was ethnic culture played a significant role in that accident. The cockpit gradient with the former military trained captain was so steep that neither of the two officers would have dared to take decisive action to prevent the accident lest they caused loss of face to the captain.
Are you denying that culture has had nothing to do with any prangs?

[Skyjob]

...Yes, the crew screwed up (in both AMS and AF447...), in a massive way. I am not disputing that fact at all, nor trying to absolve them of that claim.

But...

Amsterdam was not, in itself, the fault of mode confusion, or automation dependency..
Please stop defending that a crew was not to blame, this forum and the authoritative versions of all but Turkish reports all deny your point of view.
It was crew error, no more, no less.
If it was not, then:
- blame all the other crew for being able to fly the plane with the same problem in the weeks before (as analytical data has shown on the failed system involved it had flown many sectors with this failure present);
- blame all the other crew for not reporting the defect through the tech log accurately enough so it could get fixed;
- blame the engineers for not testing and repairing a reported system for failures, I'll help you: BITE check to see FAULT history...

Flying with a hidden defect is one thing, covered by MEL/CDL etc...
Flying with an unreported defect is another, blame the prior crews for not reporting it to the airline engineers in the only way legally possible...
Flying with a reported defect which has not had a fix attempted due poor system knowledge of engineers hides a lack of training for those engineers...
Flying with a reported defect repaired by engineers as serviceable shows there is a different reason or repair has not solved problem...

Either way, basic airmanship AVIATE, NAVIGATE, COMMUNICATE applies.
AVIATE - monitor what the aircraft is doing, especially close to ground, hands on the controls, this includes thrust levers!
This simple and effective measure would have avoided this accident and loss of life...
It is the first thing you learn when flying on your first day in the plane, the crew did not do it.

The failed component was not noticed, was not disconnected, was not recognised: crew error!
If you see throttles retarding and you are expecting thrust on engines, surely you would not only stand thrust levers up, you'd keep your hand on to ensure they stay there!

[A37575]

Are you denying that culture has had nothing to do with any prangs?

On the contrary. You may have misinterpreted what was written. Ethnic Culture has been demonstrated to have had significant influence on crew actions and lack of effective action to prevent a looming catastrophe.
For example: Training a Chinese cadet during a 737 type rating he was asked by his simulator instructor what action he would take if on a highly unstable approach and it was clear the captain was pressing on regardless of all warnings from the co-pilot and there was every indication that the aircraft would likely over-run after touchdown.

The cadet remained silent refusing to answer the question. The instructor gave him another chance and said would you consider taking over control from the captain and initiating a go-around? The cadet looked at the instructor horrified and said he would NEVER consider taking over control from a captain under the circumstances described.

That, my friend, is culture and the bane of common sense flight safety. Blind obedience to authority will never change in some cultures.

[Vessbot]

Both statements can be simultaneously true:

A) The system is poorly designed, which contributed to the accident.
B) The pilots committed an error, which contributed to the accident.

The system caused an undesirable aircraft state, and the pilots didn't catch it due to whatever combination of complacency, distraction, automation dependency, etc. It's not quantum chromodynamics.

[alf5071h]

A problem with open-ended questions is that you can find whatever you look for. Viewpoint, analysis, opinion, are all biased by the inherent human condition.

There would be greater safety benefit in considering the range of situations and context which humans have to manage. The assumption in this is that humans are influenced by the situation much more than we wish to admit or are able to identify, and thus we like to jump to easy conclusions - hindsight bias.
In most circumstances it helps to consider the human as an asset opposed to a hazard; people are doing their best in situations as they are perceived - by them, at that time.

I doubt that any of the accidents quoted involved lack of technical understanding alone; accidents involve many interacting factors, often without a dominating feature. It’s equally possible for a highly qualified crew with good technical understanding, but still encounter a situation where an appropriate understanding is not recalled or misapplied - just being human. Thus system design or situations might dominate, overcoming human ability in those circumstances.

It is disappointing that several of these accidents involved weak technical features which had previously been identified, but for various reason deemed acceptable.
777 AT has known mode weakness, 737 Rad Alt was an old, but allowable design, but different variants of aircraft incorporate auto flight alerting or disconnect software, providing additional indications, this was not fitted to the particular aircraft. N.B. Combinations of Training flights, ATC influence, and technical weakness.

Other accidents, more than those listed, involved situations where technology has been used to guard against adverse human activity (beyond reasonable human ability), but following technical failure of these guards there is the expectation that the human will manage the resulting situation - a situation beyond reasonable ability (§22)

AF 447 involved conditions beyond those assumed in certification, technology was lacking thus it has been changed; not so (AFAIK) for the lack of comparator warning in the CRJ (Sweden). Similarly for TOCW MD80 in MAD, particularly where more recent aircraft types have an alert for TOCW failure / MEL operation.

At some point during investigations and reporting of accidents, collective conclusions are formed e.g. ‘LoC’, yet timeline-wise LoC was consequential, involving human understanding and action after the initiating event - a change in situation.
This view argues that there would not have been an accident without the technical malfunction, yet there other non technical examples involving wider operational and environmental aspects which also influence human behaviour, thus technical issues are not a complete answer.

Additionally if the industry has accidents in rare circumstances which involve greater than the assumed probability of occurrence, then we have to question if the regulations or assumptions should be changed; who determines the cost benefit, who pays.

Perhaps the industry’s very good safety record is approaching a point of ‘So Far As Is Reasonably Practical’; then what.

[underfire]

A) The system is poorly designed, which contributed to the accident.
B) The pilots committed an error, which contributed to the accident.

So if the pilot does not understand the if/thens and the cascade of sequences involved in the system processes, it is the systems fault?

[semmern]

I disagree. The only reason we still have pilots is for when **** hits the fan, anything else can be automated. The radar altimeter failed and that led to the auto thrust to go to idle. The FO pushed the throttle up, let go, it went back to idle, and for the next 100 seconds all 3 of them sat there while the thrust was at idle, and the speed dropped to 83kts, 40kts below Vref.

Same for the China airlines flight. They just sat there, never used rudder trim, let the speed drop until the autopilot gave up, and barely made it out alive.

If we can’t handle stuff like this we don’t deserve to get paid to fly.

A great indicator of something being amiss with thrust and/or airspeed in the 737 is the trim wheels rolling on and on and on... great clue to intervene manually :)

[simmple]

Sorry to be simplistic but when all the bells and whistles fail, if you are a pilot and I used to be one before I was forced to become an aircraft operator! You only need the old formula pitch and power equals performance.
every aircraft works like a Cessna, piper etc. I despair at the state the industry is in when it comes to piloting skills and I only see a small snapshot.

[Vessbot]

So if the pilot does not understand the if/thens and the cascade of sequences involved in the system processes, it is the systems fault?

To the extent that the lack of understanding is due to overly complicated design with easy to miss logic traps, yes.

It's a mistake to take a moralistic stance that looks to assign fault. The pilot screwed up then what, now we can harumph sanctimoniously and feel better about ourselves? No, in the end, people's skulls get splattered and any factor that increases the likelihood is an area to focus on for improvement. It doesn't mater whose "fault" it is.

[parabellum]

There was a time when us 'old codgers' as Capt. Bloggs calls us, had to do upwards of 1500 to 4000 hours before we got anywhere near flying a shiny jet and most of that time would be spent single crew flying light twins, in all weathers, with levels of automation that ranged between nothing and not very much, our natural reaction, when things started to go wrong was to dump the automatics and fly manually, (not always a good idea). We had to be taught to believe in the automatics and bide our time and try and solve problems though the automatics, if the automatics didn't solve the problem itself. Todays 'Child of the Magenta Line' has no basic flying experience of any depth to fall back on so when things go wrong and the pilots don't fully understand the capabilities and limitations of automatics and are convinced the automated systems are more competent than the pilot and will always save them, then disaster is only a short step away.

[Vessbot]

A big problem is that "the automated systems are more competent than the pilot" is largely a true statement. From what I've seen in general, I would place more stock in the automation saving the pilot, than the other way around.

[Capn Bloggs]

From what I've seen in general, I would place more stock in the automation saving the pilot, than the other way around.
The problem Vessbot is that you haven't seen (do you fly?) all the saves that have been made by pilots but which don't get reported. AF 447 alone, I think I read that that event (or similar) had occurred 30 times previously, but with no dramas as the situation was recovered by the pilots. Bad design, pilot save. When finally pilots don't save it, much gnashing of teeth occurs blaming the drivers, who are themselves victims of Magenta Line policies of the regulators, operators and manufacturers.

[underfire]

I am reminded of Murphys original quote, (not the often misquoted "Murphys Law")

One day, after finding that a transducer was wired wrong, he cursed the technician responsible and said, "If there is any way to do it wrong, he'll find it."

[ScepticalOptomist]

Todays 'Child of the Magenta Line' has no basic flying experience of any depth to fall back on so when things go wrong and the pilots don't fully understand the capabilities and limitations of automatics and are convinced the automated systems are more competent than the pilot and will always save them, then disaster is only a short step away.

Unfortunately this seems to be true...

[Dan Winterland]

I'm always amazed by the extent that pilots are willing to blame our colleagues for assumed screw ups while secretly hoping we don't make the same mistake. And when it comes to accident investigation, blaming the operator is the easy way to get to a conclusion. In the Asiana accident at SFO, I've heard many times that it was pilot error - even mainstream media in the US made a joke about it.

But modern accident investigation has moved on from simply blaming the operator as it doesn't stop the same or a similar incident from recurring - which is the primary aim of holding the investigation in the first place. In this incident, you have to look at why the crew didn't manually apply thrust on the approach. By saying "they were stupid" stops the investigation right there and then. You think you have found the issue and when the airline trains their pilots better, the problem goes away. That's until it happens again - which it probably will.

But a thorough multi level investigation will look at the Airline's SOPs, their training system, their culture etc. And as the system correctly maintained and working as it should? Were the crew fatigued? Did they get their mandated rest period? Does the airline have fatigue mitigations in place? It will look at the airline's regulator to see how effective it is in ensuring training and safety standards are met. Then it will look at the design of the AT system. Is it fully understood by other operators using substitution tests, have there been similar incidents reported? Are similar incident actually being reported perhaps distorting the true picture? What was the certification process that led to the system being included - was it effective and did it consider all the threats at pitfalls? So much to consider!

I've flown a similar type with the Thrust Hold AT mode which caught the Asiana crew out. I was warned about it during training and that it can seriously bite you on the bum. Despite the warning in training, I've witnessed the speed reducing while a pilot says "What's it doing now?" to be told "Thrust Hold mate!" on many an occasion. I've done it myself! And at the end of a 14 hours sector after some dodgy crew rest, making an approach in tricky conditions at an unfamiliar airport in a new aircraft in your window of circadian low, I can see how all the factors stack up to make an accident like this more likely. Sure, the crew made an error. But just by pointing the finger at the user will not address all the factors.

And if you ask me my opinion about this accident, I would have to ask why the manufacturer thought it was sensible to have an AT mode which tells you the AT is working, but doesn't let you know the thrust levers won't move.

[Capn Bloggs]

Well said, Dan.

[Fursty Ferret]

And if you ask me my opinion about this accident, I would have to ask why the manufacturer thought it was sensible to have an AT mode which tells you the AT is working, but doesn't let you know the thrust levers won't move.

This. And “this is the way we did it in the sixties” is not a valid excuse.

The children of the magenta line line trope is getting tired. I’m more concerned about someone who is reluctant to embrace change (look at the incomprehensible Boeing FMAs) and who thinks that everything in aviation is lightning fast reactions and seat of the pants skills.

[KenV]

You old codgers can rant and rave all you like. The concept that a perfectly serviceable autothrottle system would just stay asleep when the speed was 30 knots below Vref is ludicrous.Is it? Really? The autothrottle system was dependent on the rad alt, so when the radalt failed, the autothrottle failed. The flight crew is not dependent on the radalt. Changing the above statement slightly results in the following truism: The concept that a flight crew would just stay asleep when the speed was 30 knots below Vref is ludicrous.

[GlobalNav]

Is it? Really? The autothrottle system was dependent on the rad alt, so when the radalt failed, the autothrottle failed. The flight crew is not dependent on the radalt. Changing the above statement slightly results in the following truism: The concept that a flight crew would just stay asleep when the speed was 30 knots below Vref is ludicrous.

I would also suggest that during the design and certification of the system, the safety analysis assumed a trained and competent aircrew, too. With hardly any change in such assumptions from the 60's and 70's.

In my opinion, the last three decades of design and operational use of automated systems in the flight deck has gradually led to less vigilant instrument pilots. Everything works so well, almost all of the time, and when it doesn't it may not be obvious, except to a vigilant grew watching the instruments instead of the system.

I don't blame the pilots, they are the victims of this systematic paradigm shift. Considering how important airspeed control is during the final approach, who would have guessed that pilots would be so inattentive (for two minutes, and this isn't the only such accident)? Unless you have been in the situation after hundreds (thousands) of approaches when "other things" held their attention, and nothing went wrong.

Think how much "better" things will become when airlines achieve their goal of single pilot airline crews, and/or "warm body" co-pilots.

[Switchbait]

Fly the plane, that’s what you are there for.

The automation is an aid.

Those of you that can’t grasp the concept that the pilot is solely responsible for the flight path, and not the autopilot, need to grow up and finally take responsibility for what you are doing.

Stop blaming the system for incompetence.

Its a scary aviation world we are getting in to, where the new generation of pilots are looking to blame the system for unintended and undesirable flight paths, rather than take responsibility for being the Pilot in Command!

The Boeing automation is simple and easy to understand. All you have to do is read the books....

Boeing also assume competent and trained pilots are flying their aircraft.

What an outrageous assumption to make!!! Who would think that competent and trained pilots would be in command of jet transport airplanes! Oh the horror of requiring such a thing!! :rolleyes:

grow up.

[alf5071h]

If a technical systems fails / malfunctions in circumstances leading to a hazardous situation, and where comparable systems / aircraft provide sufficient mitigation against this hazard, then irrespective of human performance, assumed or otherwise, then the deficient technical system should be corrected.

The debate in the above is with what is assumed to be hazardous.
The technical outcome of an accident is objective fact; but the assessment of human performance either with hindsight or expectation in future situations is always subjective, uncertain.

‘Precautionary Principle’ … defines actions on issues considered to be uncertain, for instance applied in assessing risk …
"… caution practised in the context of uncertainty" …

[tdracer]

I would also suggest that during the design and certification of the system, the safety analysis assumed a trained and competent aircrew, too. With hardly any change in such assumptions from the 60's and 70's.
With the exception of the 787, the autothrottle cert basis on all Boeing aircraft was for a 'Design Assurance Level' (DAL) B or C system (depending on which aircraft) - 'flight critical' is DAL A. In other words, a DAL B/C system doesn't have to be perfect, because it's assumed a competent flight crew will notice if the A/T isn't doing what it should and intervene... It was something of a hassle for those of us on the Propulsion side, since we had to assume the A/T could do something stupid so we needed to design our systems to account for that. I don't know if that little tidbit - that the A/T is not designed or certified as a flight critical system on most Boeing aircraft - is included in the flight crew training, but if it's not, it should be...
My understanding is they finally upgraded the DAL of the autothrottle to 'A' on the 787 (although I don't know that for a fact).

And at the end of a 14 hours sector after some dodgy crew rest, making an approach in tricky conditions at an unfamiliar airport in a new aircraft in your window of circadian low, I can see how all the factors stack up to make an accident like this more likely.
I don't dispute that fatigue likely played a factor in Asiana, but what part of landing at SFO on a beautiful, clear, sunny summer day would constitute 'tricky conditions'? If a pilot can't handle a near perfect summer day without hitting the sea wall, what chance would they have at night in a storm?

[Vessbot]

The problem Vessbot is that you haven't seen (do you fly?) all the saves that have been made by pilots but which don't get reported. AF 447 alone, I think I read that that event (or similar) had occurred 30 times previously, but with no dramas as the situation was recovered by the pilots. Bad design, pilot save. When finally pilots don't save it, much gnashing of teeth occurs blaming the drivers, who are themselves victims of Magenta Line policies of the regulators, operators and manufacturers.

This little tidbit is encouraging, but the attitude I see day in day out at the airline I fly for, is not: that handflying is an entertaining frivolity, only to be reserved for the clearest calmest of days (if even then). Competency in it is assumed, on no basis. Numerous times I've heard from check pilots and instructors "we know you know how to fly the airplane at this stage, so the focus is on [everything else]" when they actually don't know that at all. Seems like it comes out like a verbal tic. All the big talk about our substantial responsibilities is about managing the big picture and being an automation manager... as if that's something to do not in addition to knowing how how to fly, but instead of it. In all of newhire sim training, to my best memory, I did two handflown approaches. The rest was all profiles and procedures. I get thrown out onto the line since all the required boxes are checked, and then I could fly until upgrade, literally without intercepting a course or levelling off from a decent even once. And, if I followed the example from the left seat, this wouldn't be too far from the truth.

When we're getting vectored to expect a tight visual because of a storm on long final, and he's nervously fidgeting with the heading knob a few degrees back and forth while telling me not to call it in sight yet, instead of just flying it in, it's clearly revealed to me which way the automation/pilot/saving relationship is arranged.

[FlightDetent]

tdracer, that's probably not worded to describe precisely the SFO accident. Anyhow the energy level was tricky. Intercepting a standard 3 deg profile from above, with a rather low-and-close geometrical intersection point is a beast. Your mind is firmly set that you are hot and high, so you WANT idle thrust....

and then

... In fact, as you intercept the G/S, heaven forbid the AP or pilot pulling up to capture it - oh wait, there is no other way - the A/C if still with idle thrust is in a SEVERE low energy state. Add to that a bit more pull to recover the duck-under (no matter A/P or human) and you have a 7n7 with a 6-8 degree DOWN trajectory vector, full landing flap with L/G down and 5 deg NU pitch to recover the profile and it is an extremely high drag configuration. The inertia is massive.

If not anticipated it all happens very fast and the recovery N1 is in the low 80s. Feel free to ask how I know.

Another trap is how un-common it is. These days especially long-haul it is ILS to ILS and stable-coupled from 15 NM. And guys get about 2 landings a month each. The chances of recognizing not only that the situation is wrong, but how quickly and deeply bad it is about to become are practically nil. And then you are left with the reactions. Why theirs came late is elementary HF.

In this respect both AMS 737 and SFO 777 wouldn't have happened if it was not for the intercept from above to begin with, I am quite convinced.

[Capn Bloggs]

Is it? Really? The autothrottle system was dependent on the rad alt, so when the radalt failed, the autothrottle failed. The flight crew is not dependent on the radalt. Changing the above statement slightly results in the following truism: The concept that a flight crew would just stay asleep when the speed was 30 knots below Vref is ludicrous.
Ken, I was referring to the SFO 777 prang, not the 737 at AMS. The 777 was fully serviceable, but by design, the ATS didn't wake up even though the speed got to Vref-30. If what Tdracer has added is true, it seems Boeing has had a change of heart with the 787.

Fly the plane, that’s what you are there for.

The automation is an aid.

Those of you that can’t grasp the concept that the pilot is solely responsible for the flight path, and not the autopilot, need to grow up and finally take responsibility for what you are doing.

Stop blaming the system for incompetence.

Its a scary aviation world we are getting in to, where the new generation of pilots are looking to blame the system for unintended and undesirable flight paths, rather than take responsibility for being the Pilot in Command!

The Boeing automation is simple and easy to understand. All you have to do is read the books....

Boeing also assume competent and trained pilots are flying their aircraft.

What an outrageous assumption to make!!! Who would think that competent and trained pilots would be in command of jet transport airplanes! Oh the horror of requiring such a thing!! :rolleyes:

grow up.
A well-rounded, balanced view of the current state of the industry...

[underfire]

Switchbait.
Fly the plane, that’s what you are there for.

The automation is an aid.

Those of you that can’t grasp the concept that the pilot is solely responsible for the flight path, and not the autopilot, need to grow up and finally take responsibility for what you are doing.
Stop blaming the system for incompetence.
Its a scary aviation world we are getting in to, where the new generation of pilots are looking to blame the system for unintended and undesirable flight paths, rather than take responsibility for being the Pilot in Command!
The Boeing automation is simple and easy to understand. All you have to do is read the books....
Boeing also assume competent and trained pilots are flying their aircraft.
What an outrageous assumption to make!!! Who would think that competent and trained pilots would be in command of jet transport airplanes! Oh the horror of requiring such a thing!! :rolleyes:
grow up.

Bloggs
A well-rounded, balanced view of the current state of the industry...

Well stated. If the pilot does not understand the if/thens and the cascade of sequences involved in the system processes, it is the systems fault?

There is absolutely nothing in placing blame where blame belongs.

The system is there to HELP you fly the ac.

The pilots job is not to be there to take over when the automation makes a mistake. ummm, never mind, that was not the original intention of the automation.

[Capn Bloggs]

Well stated.
I was being sarcastic. That diatribe from Switchbait is one of the bigger loads of nonsense I have read.

[Fursty Ferret]

If what Tdracer has added is true, it seems Boeing has had a change of heart with the 787.


Sadly not, it’ll do exactly the same thing.

To the the poster who says that the Boeing FMAs are easy to understand if you read the manuals: I put to you VNAV climb or descent, where there is no indication whatsoever on the FMAs (or PFD for that matter) that the aircraft will or will not level off at some intermediate altitude. It can’t even handle the job of making a constraint that’s referenced to STD while QNH is set, or vice-versa.

Or the fact that approach mode only works for IAN and not an RNAV approach with multiple constraints; or the fact that you can’t arm APP until established on the localiser / FAC; or that you have to do a silly pressurisation sequence of the hydraulics / fuel pumps before engine start even though they’re all load shed anyway; or that it has no comprehension of passenger comfort in VNAV descent; or that it will exceed its thrust capability in HDG SEL at high altitudes; or that you have to use a mouse pointer to click on dinky virtual FMC buttons; or that doing direct to a waypoint doesn’t automatically engage a navigation mode; or the hold entries that would fail an IR; or the most annoying trait of all of making you tweak the HDG bug every minute or two for FOURTEEN HOURS STRAIGHT because they couldn’t figure out how to slave it to the actual heading.

Feel slightly better for getting that off my chest.

[Centaurus]

A now retired simulator instructor at Boeing told me they designed the 787 on the assumption it would be flown by incompetent pilots; hence all the protections.

[aterpster]

A now retired simulator instructor at Boeing told me they designed the 787 on the assumption it would be flown by incompetent pilots; hence all the protections.
Not doubting he said that. But, he was pulling that assumption out of his ass.

[Vessbot]

Not doubting he said that. But, he was pulling that assumption out of his ass.
I don't see that. A commercial aircraft needs to be safely and reliably operated by the least competent pilot on the seniority list, wouldn't you agree? Designing it under any other assumption would be negligent.

[KenV]

I don't see that. A commercial aircraft needs to be safely and reliably operated by the least competent pilot on the seniority list, wouldn't you agree? Absolutely NOT! What if an operator decides to hire a blind pilot? Or a pilot with mental disorders? Never never let the operator define the competency level of the pilots it hires. Commercial aircraft need to be designed to a specific competency level and then the operator and regulators must ensure that it hires and trains pilots to at least that competency level or better. Designing aircraft for low competency pilots would be negligent.

[Vessbot]

No matter who is hired, by definition someone has to be the least competent. Your position is the same as "our amps go to 11." It's one louder, you see...

[BBK]

KenV

You might want to google “window of circadian low” or maybe any study into the effects of fatigue. A competent pilot who hasn’t slept because he/she has operated a flight at the limits of allowable FDP might be a tad sleepy. Of course I’m drifting in Human Factors here. Tut tut. Let’s hark bark to the good old days when no one screwed up. You know before the “children of the magenta line”.

[tdracer]

Not incompetent as such, but do we have to design for the "99 percentile bad" pilot, which may not be far removed from incompetent... Sadly, in many cases this means making the system "less good" than we otherwise could if we didn't need to account for a sub-par pilot.

Another part of the problem is pilots switching between aircraft makes. There is a certain logic to the way Boeing systems work - and it doesn't change all that much between the various Boeing models. Fly Boeings your whole life and it all makes perfect sense. Airbus has a certain logic as well that is pretty consistent between the various model, and it makes sense to the people who have only flown Airbus. But the Boeing logic is different than the Airbus logic. Which one you think is better is largely dependent on which one you 'grew up with', both work, but they are not completely compatible with each other.
It's sort of like driving on the right or on the left - both work, both have people that think their way is better. I grew up driving on the right - it's what comes natural to me. I've driven on the left for many thousands of accident free miles when in other county's (mainly the UK and Australia) - it's takes more attention and is hence more fatiguing - but it's not all that bad so long as things don't go seriously wrong. But I also know and fear that, faced with an emergency situation where I need to take split second action, my instinct will be to 'go right' - which if I'm driving on the left could be the exactly wrong thing to do.
While it has gotten little discussion here, I'm firmly of the belief that Asiana was in no small part due to the pilot transitioning from Airbus to Boeing and that's why the aircraft systems didn't behave the way he expected.

[hans brinker]

Respectfully, I think you've both missed the point. I guess you would both argue that AF447 was solely the result of the crew, rather than the fact they lost the airspeed in the first place...

Yes, the crew screwed up (in both AMS and AF447...), in a massive way. I am not disputing that fact at all, nor trying to absolve them of that claim.

But...

Amsterdam was not, in itself, the fault of mode confusion, or automation dependency. The crew recognised the decaying speed, and that the throttles retarded automatically. They then pushed them up, and believed (and this is where their lack of systems understanding failed them) they would stay there - and through lack of basic airmanship, let the speed decay to a point where the accident was inevitable.

Consider the case of Scandinavian 751. Engine surge on the initial climb, pilot does the right thing and reduces power. But the autothrottle restored power on the engine, resulting in dual engine failure and the ensuing crash. The pilot knew nothing about that 'feature', nor did the airline. Is it still their fault for not noticing the increasing power? The moral of the story is, pilots screwup certainly. But rarely does that, in itself, cause an accident and it is fatally simplistic to simply lay the blame for a prang at the feet of the crew.

I fly the A 320, quite a few years ago as a first year fo, in a turn to final, I got the “speed, speed, speed” warning. Unsure of how to proceed, I looked to the left. He said “my controls”, realized the automation wasn’t aware we were trying to land, and said “your controls if you want them “. The speed warning is there to tell you your energy is decreasing, which is what I was trying to do. It took a good long read of the manual after landing to realize why it happened. Shortly after my upgrade I flew a few times with the autothust deferred, and I realized I had gotten very used to it working, so I made it a point to not use it on both TO and landing whenever possible. There seems to be a lot of companies/authorities that feel keeping the automation on the highest level is always preferred. Luckily for me, my company feels proficiency is important. When I say the pilots were at fault, it is part of a bigger problem. If the company/authorities won’t let the pilots fly manual it might prevent some accidents, but it will definitely cause other accidents. Having said all that:
AF 447, the only instrument that failed was airspeed, and only for the first minute. The second officer kept pulling back even after being told not to by the FO. The FO never took control when he clearly should have. For the record, I hate the Airbus design, you really can’t see what your colleague is doing.
AMS, the throttle moved back RIGHT AFTER THE FO MOVED THEM UP, the training captain should have recognized the automation wasn’t going to work.
I haven’t read the whole report on SAS, but it sounds similar, he pulled power, power came back up, he did nothing.
As pilots we are the last line of defense against all the deficiencies in airplane design, SOPs, rules, ATC errors, etc.. does that mean we are always the problem? No, but we need to be able to recognize, react and recover when something goes wrong. Failing to do so will get you killed, and criticized on pprune afterwards.

[hans brinker]

tdracer, that's probably not worded to describe precisely the SFO accident. Anyhow the energy level was tricky. Intercepting a standard 3 deg profile from above, with a rather low-and-close geometrical intersection point is a beast. Your mind is firmly set that you are hot and high, so you WANT idle thrust....

and then

... In fact, as you intercept the G/S, heaven forbid the AP or pilot pulling up to capture it - oh wait, there is no other way - the A/C if still with idle thrust is in a SEVERE low energy state. Add to that a bit more pull to recover the duck-under (no matter A/P or human) and you have a 7n7 with a 6-8 degree DOWN trajectory vector, full landing flap with L/G down and 5 deg NU pitch to recover the profile and it is an extremely high drag configuration. The inertia is massive.

If not anticipated it all happens very fast and the recovery N1 is in the low 80s. Feel free to ask how I know.

Another trap is how un-common it is. These days especially long-haul it is ILS to ILS and stable-coupled from 15 NM. And guys get about 2 landings a month each. The chances of recognizing not only that the situation is wrong, but how quickly and deeply bad it is about to become are practically nil. And then you are left with the reactions. Why theirs came late is elementary HF.

In this respect both AMS 737 and SFO 777 wouldn't have happened if it was not for the intercept from above to begin with, I am quite convinced.

You are right intercepting from above is recipe for trouble. Yesterday I saw an 18 check airman do it wrong. I don’t fly the 777, is there no way to have the AT armed to speed mode while in idle descend?

[hans brinker]

I was being sarcastic. That diatribe from Switchbait is one of the bigger loads of nonsense I have read.

not sure if I agree....

[Capn Bloggs]

Hans, I was arcing up about this dinosaur attitude that you're pilots and pilots should be able to cope if, for example, the ATS doesn't wake up. I wonder what their attitude is to GPWS and TCAS; enhancements in technology to save dumb pilots. Or are they different to a fundamentally flawed ATS design that will catch out dumb pilots?

[CurtainTwitcher]

Excuse my interruption but here are a few other bits and pieces of studies and incidents for the Original Poster:

BEA Study on Aeroplane State Awareness during Go-Around (https://www.bea.aero/etudes/asaga/asaga.study.pdf) <--- Probably what you are looking for.
B752, vicinity Gardermoen Oslo Norway, 2002 summary (https://www.skybrary.aero/index.php/B752,_vicinity_Gardermoen_Oslo_Norway,_2002) Full Report (https://www.skybrary.aero/bookshelf/books/529.pdf)


Carry on...

[parabellum]

Is it my imagination or is it reasonable to presume that some of the pilots posting here don't have one hand on the control column and one hand on the throttles at all stages of the approach, including autolands? Just the way some posts have been written perhaps.

[Vessbot]

The only reason we still have pilots is for when **** hits the fan, anything else can be automated.

Yes. But ironically due to the near-ubiquitous normal-case automation, these pilots have lost the ability to fly competently and confidently in normal situations... much less when the **** hits the fan. The only way for a pilot to justify his existence is to maintain that ability. Without that, we're already riding in drones.

The FO pushed the throttle up, let go, it went back to idle, and for the next 100 seconds all 3 of them sat there while the thrust was at idle, and the speed dropped to 83kts, 40kts below Vref.

Imagine the quote is "The FO put the yoke where he wanted, let go, it went back to the wrong place, and for the next 100 seconds all 3 of them sat there while [etc.]"

[RVF750]

Is it my imagination or is it reasonable to presume that some of the pilots posting here don't have one hand on the control column and one hand on the throttles at all stages of the approach, including autolands? Just the way some posts have been written perhaps.

I think you are probably correct. I most certainly do keep my hands on the controls during those stages. Then again I come from GA and Turboprops, the traditional route as it were. Where you learned to fly properly before you got near any automatic aids.

[tdracer]

Is it my imagination or is it reasonable to presume that some of the pilots posting here don't have one hand on the control column and one hand on the throttles at all stages of the approach, including autolands? Just the way some posts have been written perhaps.

I've been in the flight deck as an observer for countless flight tests and simulator sessions. Every single time, the pilot flying would leave one hand resting on the throttles during final approach/landing. Most of these were Boeing flight test pilots (who are generally really good stick and rudder types), but some were FAA/EASA, and a few were operator line pilots (when we did remote flight tests at an operator, they often had a rule that a company pilot had to be flying - with the Boeing pilot in the other seat).
I'd just assumed that was trained as SOP for Boeing aircraft. Also part of the reason why I think the PF being a recent transfer from Airbus was a contributing factor on Asiana at SFO.

[Vessbot]

Also part of the reason why I think the PF being a recent transfer from Airbus was a contributing factor on Asiana at SFO.

Interesting thought. In the same vein I took a quick look at the accident report of the Turkish AMS crash to see the crew's backgrounds, but it was all only 737 type ratings. Any bets on whether they habitually kept their hand on the throttles? (Not to speak of habitually flying the plane sans automatics). Lazy habits build a fatal baseline, as allowed by the automation regardless of type.

Same as the Emirates crew that attempted the idle thrust goaround in Dubai.

[BluSdUp]

You are spot on.
The non flying hand belongs on the TL ( minus V1 to ca 400 feet on T/o) for tactile feedback.
Very important on the 738 when trying to slow down on a tailwind approach and or a steeper then 3` glide when heavy.
Now for the Asiana:
First Q:
" How many pilots does it take to trash an aircraft?"
A
"Usually 3, One being an instructor and or super senior"

I am on my first zigar and second coffee , so not quite awake this balmy Sunday morning, so my numbers might be wrong from memory:
The Captain Candidate had 8000 hrs and ALL on A320 and they were sitting him direct into the LH seat to command a 777. He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident.
As mentioned before if THIS was a challenging approach , what about the one Murphy had lined up the first week after line release , on that dark and stormy night , with the toilet on fire!
A systemic fail from the company with at least two marginal crew with that a lack of self preservation.
Blame Boeing!
Why not, they should not have sold it to them in the first place?

Regards
Cpt B

[BluSdUp]

MyBad, just checked the NTSB report.
He had 9700hrs total since 1993 and plenty of 737 and some 747 time.
A320 command for the last little while. Still not a good idea as it turned out!

[Fursty Ferret]

Any bets on whether they habitually kept their hand on the throttles?

​​​​​​There's a good video on YouTube from the flight deck showing the 787 taking part in an air display.

No one has their hand on the thrust levers, so if Boeing don't consider it important then it's unlikely to be of relevance to this incident.
​​​​​​

[Capn Bloggs]

Boeing is hardly going to put in it's FCTM "keep your hands on the throttles"! :rolleyes:

From the same company that designed the ATS to stay dormant while the aeroplane crashed due to slow speed...

[Vessbot]

​​​​​​There's a good video on YouTube from the flight deck showing the 787 taking part in an air display.

No one has their hand on the thrust levers, so if Boeing don't consider it important then it's unlikely to be of relevance to this incident.
​​​​​​

There's less of a need to react quickly when you're zooming around at high speed, plus your second hand is needed on the yoke when you're wrestling a pig through the sky anyway.

But fast forward to the end to see where his hand is during a phase of flight with a higher "relevance to this incident."

[sonicbum]

You are spot on.
The non flying hand belongs on the TL ( minus V1 to ca 400 feet on T/o) for tactile feedback.
Very important on the 738 when trying to slow down on a tailwind approach and or a steeper then 3` glide when heavy.
Now for the Asiana:
First Q:
" How many pilots does it take to trash an aircraft?"
A
"Usually 3, One being an instructor and or super senior"

I am on my first zigar and second coffee , so not quite awake this balmy Sunday morning, so my numbers might be wrong from memory:
The Captain Candidate had 8000 hrs and ALL on A320 and they were sitting him direct into the LH seat to command a 777. He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident.
As mentioned before if THIS was a challenging approach , what about the one Murphy had lined up the first week after line release , on that dark and stormy night , with the toilet on fire!
A systemic fail from the company with at least two marginal crew with that a lack of self preservation.
Blame Boeing!
Why not, they should not have sold it to them in the first place?

Regards
Cpt B

Sorry but, in my opinion, this is total nonsense. The root cause of this specific accident was mainly a lack of understanding of AFDS modes and selections from the PF associated to an incorrect GS from above capture procedure and marginal adherence to company SOPs, very poor PM duties from the instructor and poor assertiveness from the 3rd pilot. PIC time on the A320 is completely irrelevant. When a trainee undergoes a new type rating he/she must work hard to clear his mind of whatever procedure he was doing on the previous type and put maximum effort in system knowledge and operations of the new type, with the advantage like in this specific instance that the trainee is within the same operator so he/she can only focus on the technical aspect of the training.
The instructor on the other hand must be extra vigilant and add to his normal PM duties the instructional inputs. This requires ability and capability to be done to very high standards simultaneously and takes time to develop for every single instructor keeping in mind that PM duties and, more than ever, Capt responsibilities will always have the priority over everything else, in other words You don't end up upside down because You are trying to let the trainee understand.

[Vessbot]

Sorry but, in my opinion, this is total nonsense. The root cause of this specific accident was mainly a lack of understanding of AFDS modes and selections from the PF associated to an incorrect GS from above capture procedure and marginal adherence to company SOPs, very poor PM duties from the instructor and poor assertiveness from the 3rd pilot. PIC time on the A320 is completely irrelevant. When a trainee undergoes a new type rating he/she must work hard to clear his mind of whatever procedure he was doing on the previous type and put maximum effort in system knowledge and operations of the new type, with the advantage like in this specific instance that the trainee is within the same operator so he/she can only focus on the technical aspect of the training.
The instructor on the other hand must be extra vigilant and add to his normal PM duties the instructional inputs. This requires ability and capability to be done to very high standards simultaneously and takes time to develop for every single instructor keeping in mind that PM duties and, more than ever, Capt responsibilities will always have the priority over everything else, in other words You don't end up upside down because You are trying to let the trainee understand.

It's an odd bit of reasoning to conclude from "must work hard to [avoid X]" where X is a factor that could contribute to an accident in a new type, that X is "completely irrelevant." If it's so irrelevant, then what's the bother working hard over it?

[sonicbum]

It's an odd bit of reasoning to conclude from "must work hard to [avoid X]" where X is a factor that could contribute to an accident in a new type, that X is "completely irrelevant." If it's so irrelevant, then what's the bother working hard over it?

Sorry but I really do not understand what You are talking about.

[Vessbot]

Sorry but I really do not understand what You are talking about.

You said that the pilot's previous experience in another type is "completely irrelevant," but in the next sentence said that he "must work hard to clear his mind of" that experience. Both of those cannot be true.

[sonicbum]

You said that the pilot's previous experience in another type is "completely irrelevant," but in the next sentence said that he "must work hard to clear his mind of" that experience. Both of those cannot be true.

I did not say that "pilot's previous experience in another type is completely irrelevant," but "PIC time on the A320 is completely irrelevant". That should clear up Your uncertainty.

[Vessbot]

I did not say that "pilot's previous experience in another type is completely irrelevant," but "PIC time on the A320 is completely irrelevant". That should clear up Your uncertainty.

It doesn't. "PIC time" is just a more specific way of describing his previous experience in that type. Maybe you're talking about his SIC time then? Or combination of PIC and SIC time? Anyway, who cares about all the exact particulars. Do you agree or disagree that his habits formed over a substantial amount of experience with the different type might have contributed in his on-the-spot mode confusion?

[sonicbum]

It doesn't. "PIC time" is just a more specific way of describing his previous experience in that type. Maybe you're talking about his SIC time then? Or combination of PIC and SIC time? Anyway, who cares about all the exact particulars. Do you agree or disagree that his habits formed over a substantial amount of experience with the different type might have contributed in his on-the-spot mode confusion?

Vessbot You keep mixing up different things all together. I was specifically replying to a comment where, amongst others, it was stated that "He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident."
Now in my opinion, in the context of this accident, this has nothing to do for the reasons already mentioned before.

Do you agree or disagree that his habits formed over a substantial amount of experience with the different type might have contributed in his on-the-spot mode confusion? of course I do, hence my comments. Again, it is specifically the experience as a Commander that is not specifically relevant in this context, but his overhaul experience on a different type was definitely a threat that was unmanaged by the crew.

[BluSdUp]

Having done a few 1000 hrs of type rating courses and some line training I would say one of the biggest problem SOME experienced pilots have is forgetting about the " Other" aircraft , when they get stressed.
Had an experienced ATR captain try to use the steering tiller on a xwind T/o during linetraining on a Do328 TP out of Fornebu Oslo.
Fortunately it did not work, would have been catastrophic.

Also had some good fun in the 737 sim watching experienced Airbus, Fokker, MD80 and Dornier pilots try to find the TOGA button on a go around.

Also going direct Long Haul captain from a different SH manufacturer is not a good idea, I think!

[sonicbum]

Having done a few 1000 hrs of type rating courses and some line training I would say one of the biggest problem SOME experienced pilots have is forgetting about the " Other" aircraft , when they get stressed.

110% agree on that. I share the same experiences and comments.

[BluSdUp]

Thanks Vessbot.

Sonicbum.
So, I concentrate on the Big Picture, always. Details are fun, but boring when after all its just a big Piper Seneca with reeeeealy slow engines on it if left at idle on short final.
Eh! ?

[sonicbum]

Thanks Vessbot.

Sonicbum.
So, I concentrate on the Big Picture, always. Details are fun, but boring when after all its just a big Piper Seneca with reeeeealy slow engines on it if left at idle on short final.
Eh! ?

Well, don't really agree on that one.
Previously You have written : "The Captain Candidate had 8000 hrs and ALL on A320 and they were sitting him direct into the LH seat to command a 777. He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident."

This is not about the big picture, it is -IMHO- simply heading in the wrong direction.
The big picture is paramount, we are all happy about that, but during investigations we must focus also on the details, understand why things went the way they did and prevent it from happening again by using the proper countermeasures.

[Vessbot]

Both the big picture and the details are equally important to focus on. I think accident investigation boards are better at identifying the details, which are more tangible and more easily describable. Such as some logic trap in this or that combination of submodes, or a seldom-encountered interaction of A and B systems... things that can be pointed to and shown that happened in a particular moment on the flight. And these can be (and should be) fixed so as not to contribute in a future accident.

But why the pilot acted or failed to act in a particular way? That's fuzzier and harder to identify. It has to do with trends, habits, and mental states. It's harder to identify as happening at X moment in time and setting off the chain of events Y and Z. And that could mean it's left out of the accident report, even though it may be just as much (or even more of a) contributor to the accident than the easily pointed out details from the last paragraph. It's identified not for X moment in time by the accident investigator, but over many flights (or decades of flights) by conscious pilots, instructors, etc., especially when they can see these trends and changes spanning over long periods of time, or over different sectors of the industry, as they observe habits and inclinations.

The thing is, no matter how carefully we cinch up every identified hole in the logic traps and system interactions (i.e., the details) a new unforeseen one is always liable to show itself in the future and be best (or only) curable by a flight crew with a grip on the big picture (i.e., the airplane is going THIS WAY, and I'm simply gonna make it go THAT WAY, with the readiness and ease of an instructor saying "I have the controls" to a pre-solo student)

[Dan Winterland]

Accident reports are variable in quality, but are generally improving. Very seldom do we see the term 'root cause' used and some investigation agencies have gone away from using the term 'cause' altogether. Accident reports should never apportion blame, so you should never see "the cause of the accident was the pilot doing xxxxx " wriiten. Investigation of human factors is changing for the better too, particularly in the field of human/machine interfaces. I have recently qualified as an accident investigator and the main emphasis on my course was human factors. Based on the premise that people don't go out to do a bad job (if they did then this becomes sabotage and a deliberate act - therefore not an accident), the investigator has to try and understand why an action made sense to the operator at the time. The factors which lead up to an accident are numerous and varied - and never simple. One basic statement such as "The pilot didn't understand the auto-thrust modes" is neither accurate or helpful. You have to look at the reasons why they were misunderstood.

It's a fascinating subject and those who wish to understand this topic more could do no better than to read 'The Field Guide to Understanding Human Error' by Sidney Dekker. It's not an expensive book, and will change your opinion on human actions, and may well change the way you act as an operator yourself. It's a 'must read' for accident investigators.

[45989]

A big problem is that "the automated systems are more competent than the pilot" is largely a true statement. From what I've seen in general, I would place more stock in the automation saving the pilot, than the other way around.
Are you a flight simmer? You don't come across as someone who really is a pilot

[sonicbum]

Both the big picture and the details are equally important to focus on. I think accident investigation boards are better at identifying the details, which are more tangible and more easily describable. Such as some logic trap in this or that combination of submodes, or a seldom-encountered interaction of A and B systems... things that can be pointed to and shown that happened in a particular moment on the flight. And these can be (and should be) fixed so as not to contribute in a future accident.

But why the pilot acted or failed to act in a particular way? That's fuzzier and harder to identify. It has to do with trends, habits, and mental states. It's harder to identify as happening at X moment in time and setting off the chain of events Y and Z. And that could mean it's left out of the accident report, even though it may be just as much (or even more of a) contributor to the accident than the easily pointed out details from the last paragraph. It's identified not for X moment in time by the accident investigator, but over many flights (or decades of flights) by conscious pilots, instructors, etc., especially when they can see these trends and changes spanning over long periods of time, or over different sectors of the industry, as they observe habits and inclinations.

The thing is, no matter how carefully we cinch up every identified hole in the logic traps and system interactions (i.e., the details) a new unforeseen one is always liable to show itself in the future and be best (or only) curable by a flight crew with a grip on the big picture (i.e., the airplane is going THIS WAY, and I'm simply gonna make it go THAT WAY, with the readiness and ease of an instructor saying "I have the controls" to a pre-solo student)

Vessbot, I may be wrong, but by reading most of Your posts it does not really seem that You are an active professional pilot otherwise You would -to a certain extent- be familiar with the logics of, to name a few, pilot core competencies, performance indicators, observed behavioural markers and threat & errors management. These are, amongst others, bread and butter for instructors & examiners and definitely a familiar environment for line pilots as well as the core foundation of incident/accident investigations.

[Vessbot]

Vessbot, I may be wrong, but by reading most of Your posts it does not really seem that You are an active professional pilot otherwise You would -to a certain extent- be familiar with the logics of, to name a few, pilot core competencies, performance indicators, observed behavioural markers and threat & errors management. These are, amongst others, bread and butter for instructors & examiners and definitely a familiar environment for line pilots as well as the core foundation of incident/accident investigations.
Maybe we have different experiences in the cockpit, but can you be more specific? Because I don't really know what I'm responding to. What are these things I should be familiar with but my posts are lacking?

[A37575]

Also had some good fun in the 737 sim watching experienced Airbus, Fokker, MD80 and Dornier pilots try to find the TOGA button on a go around.

And no doubt while stuffing around trying to find which button to press they clean forget to push the bloody throttles open as first action.

[BluSdUp]

Nope
Every single one disconnected the AT (via their old TOGA button)
Shoved the TL up and pulled the stick back so hard the AP let go!
Passenger comfort was temporarily suspended, and I hung on for dear life.

By the time they left my sim ,they were all cured of " The Other Aircraft".
Minus one crew i refused to recommend for test.But that is a story for another day.

[Ian W]

It may be a little thought provoking to think about the issues from the side of the aircraft systems designers. It is very expensive to meet an assurance level at DAL A and also automate the handling of every conceivable circumstance and failure and perhaps create some heuristic approach for failures and circumstances that are not foreseen. So instead, the approach has been for the automatics to 'gracefully' :p degrade and hand the bag of bolts to the flight crew. The flight crew are expected to be able to manually recover in the degraded/alternate state from any of the potential issues that the automatics cannot. Unfortunately, as instances quoted in this thread attest to, on some occasions the flight crew are not up to picking up the pieces when the aircraft systems peremptorily hand them control and simultaneously enter some degraded mode/alternate law. Indeed, just the complexity of managing the aircraft in its degraded mode/alternate law is sufficiently challenging for some crews.

Then there is the imaginative (mis)use of capabilities that the analysts, software designer and the certification testers did not expect: the systems equivalent of using a fire-extinguisher to hold open a fire door :}. Users will always do this with systems and they own them, but the capability that they are fulfilling with a particular function was unintended or perhaps being used outside its intended purpose, and consequently can lead to unintended consequences and exhibit 'features' that can/will catch out the unwary.

The crews that the analysts designed for 15 or 20 years ago when the design was finalized are now taking pensions (and commenting on here) and the expected capabilities and awareness of the aircraft are completely different now than they were. A lot more thought needs to be given to the human factors of the systems what was useful in the old days may be an irritant now and vice versa.

[parabellum]

It may be a little thought provoking to think about the issues from the side of the aircraft systems designers. It is very expensive to meet an assurance level at DAL A and also automate the handling of every conceivable circumstance and failure and perhaps create some heuristic approach for failures and circumstances that are not foreseen. So instead, the approach has been for the automatics to 'gracefully' :p degrade and hand the bag of bolts to the flight crew. The flight crew are expected to be able to manually recover in the degraded/alternate state from any of the potential issues that the automatics cannot. Unfortunately, as instances quoted in this thread attest to, on some occasions the flight crew are not up to picking up the pieces when the aircraft systems peremptorily hand them control and simultaneously enter some degraded mode/alternate law. Indeed, just the complexity of managing the aircraft in its degraded mode/alternate law is sufficiently challenging for some crews.

Excellent stuff Ian, best description I have heard. You have made the case for much more 'traditional' flying experience that will allow natural reactions to the unusual to develop before being let loose on an Airbus or similar. Unfortunately the aircraft has been sold as so easy to operate even a 250 hour pilot straight from flight school can fly it and ever cost conscious managements have fallen for it, the AF447 loss simply didn't penetrate the armour of the financially driven, be they a manufacturer, an operator or the flying school.
Old ways are not always bad ways anymore than the new ways are the right ways. Possibly time for the regulators to step in to scrub the Multi Engine Licence and insist on 1500 hours of GA or 1500 hours of mixed GA and light twin turbo first officer experience, anything to develop the natural reactions to an aircraft with the potential to fall out of the sky if not attended to properly?

[sonicbum]

Possibly time for the regulators to step in to scrub the Multi Engine Licence and insist on 1500 hours of GA or 1500 hours of mixed GA and light twin turbo first officer experience, anything to develop the natural reactions to an aircraft with the potential to fall out of the sky if not attended to properly?

Personally I see it in a different way. What active pilots do need, be them airline, corporate or whatever is constant and recurrent training. The minimum training and checking requirements laid down by the major authorities worldwide can be insufficient to effectively warrant complete proefficiency to those pilots who do not push themselves to dig in more for extra knowledge and practice. A big chunk of the pilot population gets in the book a few days before their recurrent PPC and most of the time already with a good idea of what is going to happen inside the box. Why does that happen ? I believe one of the main reasons is that flying pilots up to their maximum limits obviously requires subsequent rest and time for family/social activities, with less and less time that can be dedicated to self study and preparation. If Authorities / Operators increased the amount of rostered mandatory ground recurrent training and sim training and checking then it could be a big step forward. You can pick up a guy with as many hours as You want of GA to fly on the line, but if subsequently he/she doesn't keep up on track with the constant need of self updating then it will be completely useless. Now having guys on the ground studying and in the sim is expensive for airlines, who need them to fly passengers and not in front of their Ipad to periodically review the several thousand pages of different company manuals and procedures. The question is : how many of those accidents would have happened with better trained and aware pilots ? Nowadays a type rating can take 3 weeks, when I started flying it took 3 months and we had a ground instructor for every system of the aircraft. I believe there should be a way somewhere in between.
My 2 pennies

[parabellum]

Sonicbum - My only quibble with your argument is that simulators rarely faithfully reproduce the seat of the pants sensations necessary to properly fly an aircraft and so obviously lacking in some recent accidents.

[Uplinker]

Quite so, Sonicbum, but I also agree with parabellum.

Too many simulator sessions these days are box ticking exercises then-piss-off-early-to-beat the traffic. If an exercise is not flown properly, you get a minor bollocking from the TRE who tells you what you should have done, then an immediate repeat which, unsurprisingly, you get right. The box is ticked and you move on to the next exercise. But have you really learned, understood and practiced the manouever until it is second nature? Of course not.

As a long term Airbus pilot recently converted onto the Boeing, I do find the Boeing autothrust confusing. Obviously, I am not completely au fait with it yet, but it seems (to me) go to arm at strange times, and doesn’t always pick up, so you have to watch it like a hawk otherwise it can bite you in the arse by dropping out while you are re briefing because the arrival and ILS changed or whatever.

[Centaurus]

Possibly time for the regulators to step in to scrub the Multi Engine Licence and insist on 1500 hours of GA or 1500 hours of mixed GA and light twin turbo first officer experience, anything to develop the natural reactions to an aircraft with the potential to fall out of the sky if not attended to properly?
Agree whole-heartedly. Not that I fly as a passenger anymore. But when I did, I was always a trifle uneasy sitting down the back knowing on a long flight the captain was asleep in his rest bunk and a sprog second officer was in the left seat and a first officer in the right seat. In the case of the Air France A330 accident it became the second officer's "leg" and the first officer merely watched as the second officer stuffed up in weather.

[sonicbum]

Sonicbum - My only quibble with your argument is that simulators rarely faithfully reproduce the seat of the pants sensations necessary to properly fly an aircraft and so obviously lacking in some recent accidents.


Quite so, Sonicbum, but I also agree with parabellum.

Too many simulator sessions these days are box ticking exercises then-piss-off-early-to-beat the traffic. If an exercise is not flown properly, you get a minor bollocking from the TRE who tells you what you should have done, then an immediate repeat which, unsurprisingly, you get right. The box is ticked and you move on to the next exercise. But have you really learned, understood and practiced the manouever until it is second nature? Of course not.

As a long term Airbus pilot recently converted onto the Boeing, I do find the Boeing autothrust confusing. Obviously, I am not completely au fait with it yet, but it seems (to me) go to arm at strange times, and doesn’t always pick up, so you have to watch it like a hawk otherwise it can bite you in the arse by dropping out while you are re briefing because the arrival and ILS changed or whatever.


You are absolutely right. The seat of the pants sensation is almost completely absent in the sim and that is an important limit of these training devices that we should account for. The "box ticking" philosophy is one of the major concerns affecting the industry as, especially nowadays, everything must be fast and cost efficient otherwise the bean counters will see it as unproductive. Me, like I believe the majority of other trainers regardless of the type of airline, have found myself with 4 hours sim sessions filled up way above the brim with enough material to cover comfortably 2 sessions. You then end up with maybe 1 or 2 trainers signing training disruptions for lack of time whilst the majority just cuts every possible corner to finish the session, go home and chill. No need to say who then gets questioned by the training department. I honestly don't know where we are going to end up by following those principles and I praise those operators who still manage to keep the bar high regardless of how expensive it is.

[Tee Emm]

I honestly don't know where we are going to end up by following those principles and I praise those operators who still manage to keep the bar high regardless of how expensive it is.

A good example is competency in max crosswind landings during both type rating and re-currency simulator training sessions. Many low experience pilots fear crosswind landings; yet their boxes are ticked off after two or three landing attempts if they are lucky and it's on to the next sequence in the syllabus.

They lose confidence quickly especially as we all know it takes real pure flying skill to be able to consistently nail a good crosswind landing without screaming tyres and being jerked sideways. It takes at least ten landings on maximum crosswinds in the simulator before some new pilots get the hang of the de-crabbing technique. These can be done from one mile final or five mile final using re-positioning after touch down. Yet few syllabus will allow the half-an-hour of time needed for practice until certified competent.

[sonicbum]

A good example is competency in max crosswind landings during both type rating and re-currency simulator training sessions. Many low experience pilots fear crosswind landings; yet their boxes are ticked off after two or three landing attempts if they are lucky and it's on to the next sequence in the syllabus.

They lose confidence quickly especially as we all know it takes real pure flying skill to be able to consistently nail a good crosswind landing without screaming tyres and being jerked sideways. It takes at least ten landings on maximum crosswinds in the simulator before some new pilots get the hang of the de-crabbing technique. These can be done from one mile final or five mile final using re-positioning after touch down. Yet few syllabus will allow the half-an-hour of time needed for practice until certified competent.

That is very true. Unfortunately nowadays how many airlines offer the opportunity to have purely non jeopardy handling sim sessions aside from the mandatory recurrent/ppc ? I believe we can count them on one hand.