Emirates 777-31H, (EK521) Accident - Final Report Out

[paulross]

Final Report No AIFN/0008/2016, issued on 20 January 2020 published on February 6th 2020
Publication site: https://www.gcaa.gov.ae/en/Pages/NewsDetails.aspx?NewsID=490
Final report (English): https://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/124/2016-Final%20Report%20AIFN-0008-2016%20UAE521%20published%20on%206-Feb-2020.pdf

[Deepinsider]

The industry has gone the wrong way with training.

Too much say has been given to automation

Stall recovery, unusual attitudes, go-arounds, etc are such fundamental items to us all, but are not trained (basic principles) anymore as simulator sessions are based on the capabilities/proceedures of the airplane concerned.

Switch off all that stuff and give the crews a basic airframe to play with. No magic button to do what's needed!

Thrust... check it's achieved
Attitude... check your'e pointed up
Flaps... select GA position
Gear, not critical but select up if positive rate.

A bit of fun doing this kind of stuff, instead of the intricate standard lessons designed to cover various regulated required items could be worth it's weight in gold...and even more value if we enjoy it and look forward to the next SIM.

[Dave Gittins]

The gulf between my flying as a GA pilot .. wholly manually. And airline flying which seems more and more focussed on "automation must be used at all times" is widening. And it doesn't appear to be helping safety one tiny bit. Would removing the mandate to use auto throttle at all times have avoided this one ?

[73qanda]

Would removing the mandate to use auto throttle at all times have avoided this one ?
IN my opinion, yes.

[hans brinker]

The gulf between my flying as a GA pilot .. wholly manually. And airline flying which seems more and more focussed on "automation must be used at all times" is widening. And it doesn't appear to be helping safety one tiny bit. Would removing the mandate to use auto throttle at all times have avoided this one ?

The thing is, it has helped safety a lot, it is hard to point out the accidents that haven't happened. The push for automation came from pilots hand flying planes into the ground at unacceptable rates. Now we are faced with pilots who can't fly if the automation doesn't help them, but aviation is still a lot safer than it used to be...

[73qanda]

Well we can easily fix that problem with a bit of money. Just mandate 2 hours of sim time per month for every airline pilot with no automatics. Job done...what’s that? Nobody wants to pay for it? Ohh, ok.

[Dave Gittins]

No doubt about that .. I got the AAIB monthly report today and it contained a cooker fire on a 777 and a child falling off the steps of a 737 fortunately without injury. Absolute leaps and bounds from what it used to be.

The only real flying report was about inputting the wrong taxiway (and getting the wrong runway length) into the electronic flight bag at Lisbon (twice !).

BUT …. my (not a professional pilot) view is that simple flying skills and situational awareness would avoid the automation gotchas as well.

[roger1NP]

Well we can easily fix that problem with a bit of money. Just mandate 2 hours of sim time per month for every airline pilot with no automatics. Job done...what’s that? Nobody wants to pay for it? Ohh, ok.

Exactly, they all think about the lowest prices in solving any problem.

[safetypee]

73qanda, et al,
There is no single method of resolving situations like this. Training is not a solution for every situation, neither automation.
Whatever we might think we have trained pilots to do, not everyone will act in that way, or see situations as trainers or rule-makers expect us to see; training has no guarantee of success.
Automation has a place, but every new automatic feature has ability to introduce its own situation-related hazard.

These safety situations are never ending challenges, often unsuitable for conventional intervention, thus require alternative views, thoughts and action, often all in combination. Without change all that we might do is chase our own tail, reactive safety, continually debate cause and 'solution' for what we might judge as low probability low risk situations, and then without agreement or action. All we do is fix the last accident, but its the next one which will 'get' us.

In this accident training might have helped, so too a better design of automation. Our choice is with hindsight, where the challenge is to foresee such situations and avoid them, require improved technology and the best of human abilities to manage situations which we have difficulty in imagining.

[Fogliner]

What if anything does 700 liters of water do to the C of G once released from where it's supposed to be? It has to weigh quite a bit.
What happens to the free water in unheated areas at altitude for example freeze thaw cycles and structure?
Regards

Fog

[bburks]

Well we can easily fix that problem with a bit of money. Just mandate 2 hours of sim time per month for every airline pilot with no automatics. Job done...what’s that? Nobody wants to pay for it? Ohh, ok.

Nah.....just manually fly the airplane whilst out flying the line.

[cashash]

What if anything does 700 liters of water do to the C of G once released from where it's supposed to be? It has to weigh quite a bit.
What happens to the free water in unheated areas at altitude for example freeze thaw cycles and structure?
Regards

Fog

When it thaws it runs out of the drains in the bilges. So no structural damage as such.

[Twitter]

What if anything does 700 liters of water do to the C of G once released from where it's supposed to be? It has to weigh quite a bit.
What happens to the free water in unheated areas at altitude for example freeze thaw cycles and structure?
Regards

Fog

700 Liters H2O weighs, by definition 700kgs.
.7 of a ton or roughly 9 passengers.

[Centaurus]

https://www.gcaa.gov.ae/en/ePublicat...6-Feb-2020.pdf (https://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/124/2016-Final%20Report%20AIFN-0008-2016%20UAE521%20published%20on%206-Feb-2020.pdf)

Tried to download this report but it was obvious it was going to take a very long time so gave up. Any idea of another way of obtaining a faster result?

[Flo121142]

Nah.....just manually fly the airplane whilst out flying the line.
Thats exactly what is needed...most people won’t disconnect the automatics until they get a landing clearance, won’t fly autothrust off, won’t fly manually in IMC etc etc. Obviously if you are getting overloaded AND automation can help you, use it (there are also cases where automation increases the workload, in that case disconnect it or go back to basic modes)...but if pilots feel „overloaded“ due to the simple fact that they are in IMC they are maybe in the wrong business (and the excuse „But a manual flown go around is challenging“ does not cut it - after rotation to initial climb attitude the autopilot can be reengaged on some/most airplanes go around modes will automatically come back on the FMA even if the approach was flown raw data...).

[malanda]

https://www.gcaa.gov.ae/en/ePublicat...6-Feb-2020.pdf (https://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/124/2016-Final%20Report%20AIFN-0008-2016%20UAE521%20published%20on%206-Feb-2020.pdf)

Tried to download this report but it was obvious it was going to take a very long time so gave up. Any idea of another way of obtaining a faster result?
Try again. It just took 6 seconds for me on a fairly slow line

[parkfell]

When you teach MCC/JOC/APS/MPL on the Boeing 737, the customer is moving from a light twin 2MT to a training weight of 60+MT. Apart from the first real experience of inertia, full automation is introduced.

It is critical from a very early stage the correct protocols are observed.

The use of A/T is highly addictive especially when linked into the TOGA mode. They must be taught to follow the TLs forward every time the TOGA button is pressed.

When they forgot to follow through, you fail the A/T and let nature take its course......they soon learn. Their brains are hardened & they are unlikely to forget.

“Make as many mistakes as you want, but only make the same mistake once”

My past students may well be having a sense of déjà vu........

[tdracer]

The use of A/T is highly addictive especially when linked into the TOGA mode. They must be taught to follow the TLs forward every time the TOGA button is pressed.

When they forgot to follow through, you fail the A/T and let nature take its course......they soon learn. Their brains are hardened & they are unlikely to forget.



Kudos for that. Proper use and monitoring of the autothrottle has suffered with the advent of FADEC - back when there were cables hooking everything to the thrust levers, it wasn't particularly uncommon for high down stream cable forces to cause the throttle clutch to slip on one (or more) engines and the associated thrust lever to lag. Hence the need to 'follow the throttles'. With FADEC, such problems are rare (although they do still happen on occasion due to an obstruction in the aisle stand itself), allowing some pilots to become lazy...

[Socalbug Smasher]

Exactly, they all think about the lowest prices in solving any problem.

Right but if all the airlines HAD to do it the cost increase would be the same for everyone so in theory they could/should all raise the prices the same... seems logical but then again we are dealing with airline managers !!!!

[B772]

Centaurus. The Library in Keilor Rd Niddrie has 'fast' internet.

[Kennytheking]

The discussion here is of academic interest only and probably belongs in another thread on automation. The Operator in question here does not allow the use of manual thrust, or raw data, at all. Mistakes can be career ending. I fly almost 1000 hours per year and the last thing I feel like after a 15 hour flight arriving at my circadian low is to prove my mettle by challenging myself to a manually flown approach.

Address those issues first before calling the pilots lazy.

[73qanda]

In this accident training might have helped, so too a better design of automation. Our choice is with hindsight, where the challenge is to foresee such situations and avoid them, require improved technology and the best of human abilities to manage situations which we have difficulty in imagining.
I don’t really agree that our choice is with hindsight.
The reliance on the auto-thrust in high workload situations on types where it is engaged for every departure, cruise and landing has been discussed for years. From memory I think it might have even come up in the 777 accident report that cart-wheeled in the states.
In a high workload situation the basics of flying should be available through muscle-memory.
When they forgot to follow through, you fail the A/T and let nature take its course
Sounds like good training to me.

[Fursty Ferret]

The report seems to overlook the fact that TOGA buttons are a stupid design in the first place, especially with FADEC. Regardless of your opinion of Airbus non-moving thrust levers, this is an aspect they got absolutely spot on.

Go-around = firewall the thrust levers. None of this messing around with buttons (accidentally disconnecting the AT instead of TOGA and vice-versa is still a common problem), and you can get rid of the utterly pointless “HOLD” mode that’s a hangover from **** design* in the 70s.

* HOLD actively disconnects power from the autothrottle servos in two separate ways. God only knows what happened that required this to be introduced in the first place.

[Deltasierra010]

“The Operator in question here does not allow the use of manual thrust, or raw data, at all.”

in this case neither pilot realized that the wheels had touched down and Auto Go Round had been inhibited, there must be cases where GA has to be done after touch down, therefore manual thrust would have to be used.
Is inhibiting auto throttle as soon as the gear touches down a good idea and why is it not cancelled when the GA button is pressed

That aside, because following through every automatic action monitoring becomes casual, in a Go Around situation which is uncommon I would be on those throttles immediately as would any GA pilot, rules or no rules.

[vilas]

May not be desirable but there are two different go around procedures in Boeing. Goaround without touchdown is the much practiced even experienced event. The need for the other after touchdown procedure is so rare that one may not remember when needed. Manufacturer may or may not change it in near future but if it is included in approach briefing it will prevent recurrence of this accident. Even mere knowledge that TOGA switches won't work is enough to execute it.

[Kennytheking]

The report seems to overlook the fact that TOGA buttons are a stupid design in the first place, especially with FADEC. Regardless of your opinion of Airbus non-moving thrust levers, this is an aspect they got absolutely spot on.

Go-around = firewall the thrust levers. None of this messing around with buttons (accidentally disconnecting the AT instead of TOGA and vice-versa is still a common problem), and you can get rid of the utterly pointless “HOLD” mode that’s a hangover from **** design* in the 70s.


Fursty, as a bus driver I am in complete agreement with your sentiment. However, the report did not overlook the poor design at all. The investigation can't really tell Boeing their system is junk. That would be apportioning blame which is not the idea of accident investigation. They did highlight several shortcomings in the combination of system & procedure. Boeing will have some thinking to do after reading the report but, unfortunately, will probably follow their standard line of pilots should know what they are doing in order to avoid any product liability.


“The Operator in question here does not allow the use of manual thrust, or raw data, at all.”

in this case neither pilot realized that the wheels had touched down and Auto Go Round had been inhibited, there must be cases where GA has to be done after touch down, therefore manual thrust would have to be used.
Is inhibiting auto throttle as soon as the gear touches down a good idea and why is it not cancelled when the GA button is pressed

That aside, because following through every automatic action monitoring becomes casual, in a Go Around situation which is uncommon I would be on those throttles immediately as would any GA pilot, rules or no rules.

DS10, the reason the TOGA switches are disabled on the ground is to prevent problems when they are triggered accidently during ground operations.But yeah, that is a bandaid on a very poor design.

[Centaurus]

Go-around = firewall the thrust levers. None of this messing around with buttons

Embedded at page 87 of the GCAA accident report, and edited for brevity, the investigator concludes:

"that a manual advancement of the thrust lever followed pushing to TO/GA switch as the aircraft gains altitude will ensure that the crew will remain in control and maintain full awareness of change in engine thrust.... the investigator recommends that the FAA performs a safety study in consultation with aircraft manufactures for the purpose of enhancing the autothrottle system and TO/GA switch inhibit logic so that pilot errors due to overreliance on automation will be avoided".

There is more, but turn to page 87 if desired. Trigger Alert - the complete report takes a lot of reading.

Manually advancing the thrust levers towards GA and then pushing TO/GA as a secondary action, is good airmanship during a low altitude go-around. At the very least, a pilot can feel the thrust increasing rather than assuming power will increase on pushing a button.

The momentary hesitation and initial confusion that is bound to occur if pushing TO/GA fails to give the expected increase in power can lead to a critical situation as the crew of the ill-fated Emirates 777 discovered to their cost.

[golfyankeesierra]

Go-around = firewall the thrust levers. None of this messing around with buttons
Except that you need them for f/d guidance. And automatic go around as well (which btw in some situations like IMC is far more desirable then a manual one. There have been many accidents due to somatogravic illusions and A/P doesn’t suffer from that).

But as far as thrust goes, I agree that it is wrong that Boeing has long ago changed SOPS during g/a to hit the button first and then ensure thrust is set, without hanging on to the well established habit of shoving the thrust levers forward.

[PiggyBack]

The gulf between my flying as a GA pilot .. wholly manually. And airline flying which seems more and more focussed on "automation must be used at all times" is widening. And it doesn't appear to be helping safety one tiny bit. Would removing the mandate to use auto throttle at all times have avoided this one ?

I am not a pilot so feel free to ignore my comment but all the evidence suggest that safety has improved enormously. I suppose there is room to argue that the reason for this is something other than increased automation/support for the pilots from aircraft systems but this seems unlikely and it would need some very strong evidence that this was the case.

See for example:
https://aviation-safety.net/graphics/infographics/Fatal-Accidents-Per-Year-1946-2017.jpg
https://aviation-safety.net/graphics/infographics/Fatal-Accidents-Per-Mln-Flights-1977-2017.jpg

I do work in the design fo safety related systems in all sorts of areas and a common phenomenen is a resistance to systems designed to assist and to prevent forseeable errors which have severe consequences when it is seen as redcing teh skill, prestige, authourity of operators. The reality is that the safest systems are ones in which automation/intelligent systems, people, training and procedures work together covering the weaknesses of one approach with the strengths of another. Automation is not a silver bullet, it won't solve every problem, it will introduce some new problems, but used judicously it will help. A view that automation per se is bad will definitely hinder progress towards being even safer.

[Twitter]

Except that you need them for f/d guidance. And automatic go around as well (which btw in some situations like IMC is far more desirable then a manual one. There have been many accidents due to somatogravic illusions and A/P doesn’t suffer from that).

But as far as thrust goes, I agree that it is wrong that Boeing has long ago changed SOPS during g/a to hit the button first and then ensure thrust is set, without hanging on to the well established habit of shoving the thrust levers forward.u no

The capt was flying the HUD. This requires the toga to be actuated, just as the FD does. What both then show is the GA pitch. If you are in a wind shear close to ground recovery, however the drill is to get every last bit of energy out of the aircraft to get clear of the deck.
That requires pitch above - and IAS below GA values - until clear of ground. And by the way in the latter case, our company required AP / ATS off, as first actions (followed by much pitch up and thrust increase to the stops) so the toga only affected the flight guidance items - which anyway don’t display what you are temporarily trying to fly.
In a fatigued situation the choice might not be apparent.

[Fursty Ferret]

Except that you need them for f/d guidance. And automatic go around as well (which btw in some situations like IMC is far more desirable then a manual one. There have been many accidents due to somatogravic illusions and A/P doesn’t suffer from that).

Certainly on the Airbus setting the thrust levers to the TOGA detent (ie fully forward) triggers the go-around mode anyway (provided the flaps are at least position 1). Trivial to sense this thrust lever position on any aircraft type.

[BizJetJock]

Am I the only one to think that there was a complete failure of workload management and prioritisation that the F/O was talking on the radio replying to tower before the Captain had even called for gear up? Several airlines used to have an SOP of no R/T below 1000 feet agl on a go around. I can't help thinking that if the PM had not been distracted he might actually have monitored the EPR as required and noticed in time - which is what I always thought the M in PM was meant to be about...

[Hot 'n' High]

Am I the only one to think that there was a complete failure of workload management and prioritisation that the F/O was talking on the radio replying to tower before the Captain had even called for gear up? ....... I can't help thinking that if the PM had not been distracted he might actually have monitored the EPR as required and noticed in time .....

My thoughts too - and, while the Report identifies the revised clearance call as a contributing cause, it is the 11th and very much last in the list! I'd put it much, much higher up there.

That call from ATC could have easily waited and, to me, demonstrates a lack of ATC understanding of what such manoeuvres involve for the aircrew and how long it takes to execute the proceedure. At the very least, ATC should wait till the crew have called "Going Around" which is also effectively the crew saying "OK, I'm ready to talk now!". I may have missed that in the report but it seems they never got the call out.

Also, to terminate the distraction, a swift "Standby!" would have been a good response - but the distraction should not have happened.

I did note the report used the phrase "the primary task of [flying] was momentarily affected ". Sort of implies that (a) it was a very short call + response and (b) completely misses out the subsequent "OK, so what was I doing before I was rudely interrupted by the radio" moment afterwards which would have added to the delay in getting back on task - which really never happened - hence the result.

Is that a deliberate lifting of the carpet to save ATC embarrassment?

[b]H 'n' H just observes...

[tdracer]

The issue with simply putting the thrust levers full forward to command a go-around on any Boeing is that - unlike Airbus - the thrust lever position always determines the thrust command to the engine. So putting the thrust levers to the firewall will give you max TO thrust for those conditions - not always wanted, needed, or even desirable for a go-around (especially with a light aircraft).
It used to be taught for the PF to keep on hand lightly on the throttles during critical flight phases - especially final approach/landing - to know what the engines were doing, and to guard against a potential autothrottle malfunction. Don't they teach that anymore?

[The Banjo]

The issue with simply putting the thrust levers full forward to command a go-around on any Boeing is that - unlike Airbus - the thrust lever position always determines the thrust command to the engine. So putting the thrust levers to the firewall will give you max TO thrust for those conditions

Yes, until you take the hand pressure off the levers. Depending on the A/T mode the levers(thrust) may well retard back to a previous setting will it not?

[tdracer]

Yes, until you take the hand pressure off the levers. Depending on the A/T mode the levers(thrust) may well retard back to a previous setting will it not?
The thrust lever position will still determine the what the engines do. Which is why it's trained (or at least used to be trained) to keep a hand on them in case a miss-configured autothrottle or malfunction attempts to move them from where the PF wants them to be.

[josephfeatherweight]

It used to be taught for the PF to keep on hand lightly on the throttles during critical flight phases - especially final approach/landing - to know what the engines were doing, and to guard against a potential autothrottle malfunction.
Absolutely the correct technique, IMHO.
So putting the thrust levers to the firewall will give you max TO thrust for those conditions - not always wanted, needed, or even desirable for a go-around (especially with a light aircraft).
This is a new concept to me - in the few jet aircraft I have flown, EVERY go-around was flown with TO thrust until level-off. I have never heard of the option of using less than TO thrust for a go-around - what is the PM meant to answer with when you say "Check Thrust"? Not having a go, genuinely interested in this new (to me) idea.

[Check Airman]

Absolutely the correct technique, IMHO.

This is a new concept to me - in the few jet aircraft I have flown, EVERY go-around was flown with TO thrust until level-off. I have never heard of the option of using less than TO thrust for a go-around - what is the PM meant to answer with when you say "Check Thrust"? Not having a go, genuinely interested in this new (to me) idea.

Airbus has a soft GA feature where you select max thrust momentarily, then go back to a lower setting before finally setting climb thrust at the usual altitude. This reduces the rate of increase of both kinetic and potential energy, particularly when light and with a low altitude level off.

My company has made a poor man’s version of this, and it’s a**holes and elbows trying to do all the call outs (6 in all before we get to “positive rate”). Needless to say, I’m not a fan.

[ReturningVector]

Absolutely the correct technique, IMHO.

This is a new concept to me - in the few jet aircraft I have flown, EVERY go-around was flown with TO thrust until level-off. I have never heard of the option of using less than TO thrust for a go-around - what is the PM meant to answer with when you say "Check Thrust"? Not having a go, genuinely interested in this new (to me) idea.

We do have a ‘discontinued approach’ procedure in the books, which is used when a G/A is required during earlier stages of the approach, close below or above the missed approach altitude and far away from the MAPt.

Involves leveling of in ALT mode and climbing or descending to the missed approach altitude in Level change or V/S etc.

Safe to say that procedure doesn’t apply to this incident by the way :)

[josephfeatherweight]

Understood - thanks for the explanation - I guess I wasn't really considering the "early missed approach" scenario, more the "missed approach from minima" or low level go-around.

[tdracer]

Boeing has two go around settings (I'm speaking widebodies, but I suspect the 737 is more or less the same). One push gives a basic go-around thrust for (IIRC) 2,000 ft/min climb, a double push gives max rated thrust.
In the pre-FADEC era, or if operating FADEC in hard Alternate mode, pushing the throttles to the firewall can result in a major overboost of the engines (I know of a few stories where they pilot forgot they were in Alternate mode or EEC OFF - did you know a JT9D can reach 2.0 EPR near sea level :eek:). So while it should be safe to firewall the throttles with FADEC in normal mode, it would require a different procedure for Alternate mode or pre-FADEC aircraft (recall there are 767 operators that have both FADEC and non-FADEC aircraft) - obviously undesirable.

[Centaurus]

The capt was flying the HUD.

That comment brought back a memory of watching a MD80 (stretched DC9) landing on the 5600 ft length runway on Nauru atoll, Central Pacific around 1984. I was a B737 pilot at the time and had operated out of Nauru many times. There are no overruns at the end of the only runway 12/30 - only massive rocks which would tear open any aircraft.

The MD 80 seemed quite high over the fence compared to a 737 approach using T-VASIS. There was a long float after initial touch down which was well into the runway. The aircraft stopped at the extreme end after heavy braking. It was a close thing.

I later talked to the captain of the MD80 which was on a Good-Will flight around the world. Neil Armstrong the astronaut was on the aircraft.
The captain said he used the HUD for landings. Certainly in this case, the HUD nearly pranged him and I saw no value in using a HUD on a sunny day on a short runway where there were ample visual cues and a T-VASIS for glide slope guidance

While I can understand that today's HUDS are much more sophisticated than in 1984, I still question it's use when it is simply an aid to landing but yet has its limitations. Like the Fly Dubai 737 go-around accident where I believe there was evidence the PF was locked on his HUD. In following its guidance for the go-around at night the PF flew the 737 into a spiral dive from a steep go-around climb. I understand the HUD was not designed for such an extreme manoeuvre but the company demanded its crews use the HUD for all landings.

[Twitter]

That comment brought back a memory of watching a MD80 (stretched DC9) landing on the 5600 ft length runway on Nauru atoll, Central Pacific around 1984. I was a B737 pilot at the time and had operated out of Nauru many times. There are no overruns at the end of the only runway 12/30 - only massive rocks which would tear open any aircraft.

The MD 80 seemed quite high over the fence compared to a 737 approach using T-VASIS. There was a long float after initial touch down which was well into the runway. The aircraft stopped at the extreme end after heavy braking. It was a close thing.

I later talked to the captain of the MD80 which was on a Good-Will flight around the world. Neil Armstrong the astronaut was on the aircraft.
The captain said he used the HUD for landings. Certainly in this case, the HUD nearly pranged him and I saw no value in using a HUD on a sunny day on a short runway where there were ample visual cues and a T-VASIS for glide slope guidance

While I can understand that today's HUDS are much more sophisticated than in 1984, I still question it's use when it is simply an aid to landing but yet has its limitations. Like the Fly Dubai 737 go-around accident where I believe there was evidence the PF was locked on his HUD. In following its guidance for the go-around at night the PF flew the 737 into a spiral dive from a steep go-around climb. I understand the HUD was not designed for such an extreme manoeuvre but the company demanded its crews use the HUD for all landings.


I remember the MD-80 HUD quite well. For approach there was an ILS mode, which gave the same guidance as the FD, albeit with a dot to aim for rather than needles. Using this and Autoland we could fly Cat111 to 20ft RA min, as the GA mode counted as a backup for the AP channel.
Then there was a visual mode. I never really liked it. You aimed an element in the display at the desired touchdown point and when around 50ft RA it gave you a flare to a very soft landing. While concentrating on the guidance it was easy to stop concentrating on the visual landing clues. I could imagine folk might use it to give a VIP a soft touchdown but I preferred to use the Mk1 eyeball and get down at the right spot.

[G-V]

Would removing the mandate to use auto throttle at all times have avoided this one ?

I am quite sure, that without automation we would have more accidents. Unfortunately. There are way too many below avarage pilots around and the industry has to respond for this fact. Unfortunately.

[boaclhryul]

There are way too many below avarage pilots around...

The oft-quoted 50% comes to mind. Complemented by the 50% above average.

[stilton]

Why would you ever want more than 2000fpm on a go around ?


This is one of many well thought out features on the 757 / 767


One of the biggest challenges on go arounds (which we rarely do) is an excessive rate of climb approaching a low altitude level off mandated on the missed approach and / or by ATC


Rarely do you ever need more than that, a positive but smooth thrust increase to 2000fpm and with far less pitch coupling is good strategic planning far less likely to result in an altitude overshoot


I remember selecting go around in the MD 80 at on a few occasions, with its crude autothrottles it was such a massive thrust increase and pitch change it was all you could do to stay ahead of the aircraft and level off when required


If you need more power it’s there, otherwise I think it’s a fine system

[777boyo]

Anyone who ever performed a Go-Around on a light A310-300 will appreciate exactly why 2000 fpm is a Good Thing!
7B

[Airbubba]

Anyone who ever performed a Go-Around on a light A310-300 will appreciate exactly why 2000 fpm is a Good Thing!
7B

Amen to that one! :D

The 'bus goes to full TOGA and doesn't throttle back in the climb. With a short local captain holding the yoke and a seat rail coming unlatched on the pitchup it makes for an impressive airshow. ;)

[Uplinker]

The report seems to overlook the fact that TOGA buttons are a stupid design in the first place, especially with FADEC. Regardless of your opinion of Airbus non-moving thrust levers, this is an aspect they got absolutely spot on.

Go-around = firewall the thrust levers. None of this messing around with buttons..................

Without wishing to turn this into Airbus vs Boeing, the Boeing auto-thrust seems a peculiar beast and I agree with Fursty on this.

In manually flown Airbus FBW G/A; you push the thrust levers fully forward - click, click - with your inboard hand. Very little effort is required and you will not over-thrust the engines. Pull gently back on the joystick, needing only the strength in your outboard wrist, to set +15° pitch. You could then let go with both hands and the aircraft would stay in the attitude it was put.

I only know the 737: the yoke requires arm muscles to pull it back - or to push it to counter the power/pitch couple. To guide in pitch accurately, a pilot might want to use both hands on the yoke to give finer control, and to trim in pitch or to add strength if the aircraft is initially mistrimmed. So s/he will want to take their inboard hand off the thrust levers as soon as possible and therefore has to rely on the TOGA switches and PM to set thrust. This takes away their haptic feedback of where the thrust levers are, at a time when their attention will be focussed on the PFD to check pitch and ROC.

Not having flown it; Would a 777 pilot want to put both hands on the yoke as soon as possible?
Is there a power/pitch couple on a 777 when manually flown?
Does 777 have auto pitch trim when in manual?
Does the 777 yoke stay where you put it if released, or would it return to trimmed attitude?

A general point about automation; Yes, we could all fly around fully manually all the time. Then we would no doubt all be able to physically control the aircraft very well, despite their various foibles. But it is knackering, so FTLs and flying during the WOCL would have to change. RVSM, LVP and RNAV approaches would not be possible and Long-haul would need several crews on each aircraft.

So we need automation, and this is not a weakness - no more than driving a car with an auto gearbox and cruise control/speed limiter. On the contrary; it frees pilots to be more vigilant about the overall flight. The challenge is that automatics need to be designed to work properly and intuitively with human beings. Airbus FBW comes very close to this, I don't know about Boeings or other types?
.

[Stanley Eevil]

Too much automation biting pilots in the arse again.
This would never have happened on the VC10.

[ATC Watcher]

Too much automation biting pilots in the arse again.
This would never have happened on the VC10.
no, but something else would likely have happen then, .
Only 54 VC10 buit, 9 accidents , (OK 3 were loses due hijacking ) but still 6 valid .
B777 production is around 2000 with 9 hull losses , to match the VC10 there would need to be around 200 B777 hull losses....
other times...

[M.Mouse]

Not having flown it; Would a 777 pilot want to put both hands on the yoke as soon as possible?
Is there a power/pitch couple on a 777 when manually flown?
Does 777 have auto pitch trim when in manual?
Does the 777 yoke stay where you put it if released, or would it return to trimmed attitude?

Both hands not required although the control forces are clearly greater than that of an Airbus sidestick.
On both the B777 and B787 there is no pitch/power couple, the Primary Flight Computers take care of that.
Pitch trim is manually applied and is slightly different in concept from other Boeings in that the aircraft is trimmed to a speed. When in trim and at that speed the aircraft will remain at whatever pitch atttude the pilot selects. If the speed increases or decays the aircraft will not be in trim.

[Uplinker]

Thanks Mr Mouse.

So......I presume then that a go-around in a 777 is not particularly challenging in terms of yoke forces and controlling the pitch and the trimming? so it seems weird that PF and PM both missed noticing that the thrust levers were not pushed fully or nearly fully forward? And that the engines had not markedly increased N1/EPR.

As I say, I've never flown the 777.

[212man]

In following its guidance for the go-around at night the PF flew the 737 into a spiral dive from a steep go-around climb

Wasn't a spiral

[tdracer]

Thanks Mr Mouse.

So......I presume then that a go-around in a 777 is not particularly challenging in terms of yoke forces and controlling the pitch and the trimming? so it seems weird that PF and PM both missed noticing that the thrust levers were not pushed fully or nearly fully forward? And that the engines had not markedly increased N1/EPR.

As I say, I've never flown the 777.
Uplinker - since the 777 is FBW, the yoke forces are artificial (generated by the FBW s/w). By design, as long as you are near the normal flight envelope, the yoke forces are very benign. As I've posted previously, Boeing teaches (or at least used to) the PF to keep one hand lightly on the thrust levers during the critical flight phase of approach/landing so the PF knows the A/T is active and doing what it should.
However if the aircraft is significantly outside the normal flight envelope, the forces increase - again by design - as a sign that you are somewhere you probably shouldn't be. During the Asiana 777 SFO investigation, John Cashman (one time 777 Chief Pilot) testified that the yoke force required to keep the nose up at such critically low airspeeds would have been around 80 pounds :eek: - well beyond what most pilots could do with one hand - making it painfully obvious that the Boeing recommended procedure of 'following' the thrust levers with one hand wasn't happening.
Personally I think the biggest lesson learned out of the Asiana SFO crash was that more training should be mandated for pilots switching between Airbus and Boeing (or visa-versa) to account for the fundamentally different flight deck philosophies...

[jmmoric]

Remember that the control of the aircraft always has priority... the same goes during go-arounds.

We are again and again told that the go-around procedure is a high workload situation for airliners, hence we're also told not to talk to, or give unnessecary instructions to aircraft executing a go around.

When it comes to wind shear, it is, or can be, characterized as an unusual situation, since we don't expect aircraft to follow a missed appraoch.... most procedures calls for climbs straight ahead at full thrust encountering such, risking overshoot of missed approach altitudes and deviation from tracks.

So from my point of view, and probably most ATCO's now a days, aircraft going around... give them time... don't expect them to do at described.... keep the all the "unusual situation" accronyms/abbreviations in mind, ASSIST/RISC/TAS/SSSS etc. etc.

Not handling a go-around as an emergency, just being a bit cautious with them.

[Uplinker]

Hi tdracer

Uplinker - since the 777 is FBW, the yoke forces are artificial (generated by the FBW s/w). By design, as long as you are near the normal flight envelope, the yoke forces are very benign.............However if the aircraft is significantly outside the normal flight envelope, the forces increase - again by design - as a sign that you are somewhere you probably shouldn't be.....................the yoke force required to keep the nose up at such critically low airspeeds would have been around 80 pounds :eek: - well beyond what most pilots could do with one hand..........


Strange to engineer a system that way. You have hydraulic power, you have FBW, why make the controls hard to hold accurately? - just design the FBW to protect the aircraft without making it hard to fly.

I personally find it awkward to hold significant force on a yoke and accurately control pitch, and have to trim as well - with just one hand. I would want to get both hands onto the yoke, hence my earlier questions.


My bolds

[tdracer]

Hi tdracer



Strange to engineer a system that way. You have hydraulic power, you have FBW, why make the controls hard to hold accurately? - just design the FBW to protect the aircraft without making it hard to fly.

I personally find it awkward to hold significant force on a yoke and accurately control pitch, and have to trim as well - with just one hand. I would want to get both hands onto the yoke, hence my earlier questions.


My bolds
The yoke forces on the 777 are intended to mimic what you'd feel in an old fashioned cable controlled aircraft (the 787 is similar). As you pull into a stall, the yoke force need to keep pulling into the stall increases rather dramatically. This gives very strong, tactile feedback of what you and the aircraft are doing - and it's required by the regs (I assume Airbus managed to get an exemption to those regs since in Normal law you can't go there - of course in Direct law you can, as was demonstrated so dramatically and tragically on AF 447).
This requirement was also the genesis of MCAS, since on the 737 MAX those big engines negate the increase in stick force required to pull into a stall.
That the ASIANA pilot didn't know or recognize that having to pull back so hard meant something was very seriously wrong is a big black mark against the AB to Boeing training he received.

[Uplinker]

The report won't download for me any more, so I can't check the details, but I wonder why neither pilot noticed that the engines were not spooling up?

Airbus non-moving thrust levers are often criticised, but at least they mean you must always look at the N1/EPR gauges to see what is going on, and this becomes an ingrained part of an Airbus FBW pilot's scan.

Why these pilots did not do so is an interesting question. It seems to me that the moving thrust lever philosophy has some flaws. There have been accidents, such as the 777 crash into SFO, where the levers did not move despite the lack of aircraft energy needing them to, but this was missed.

I wonder if they are sometimes used as a proxy for the N1/EPR gauges, leading to a lack of scan? This is usually not a problem, except when the pilot is expecting the levers to move without further contact, after the TOGA switch is pressed, and the pilot's attention is elsewhere. With FADECs, there is surely no need for a TOGA switch - you could simply push the levers fully forward, and the FADECs would prevent any excedences.

[ATOguy]

SOPs
unfortunately for your rant, it is not backed up by the facts. If you read the report it is quite clear that the “long landing” automatic call out came after the go around had commenced.

[Kennytheking]

Ok ... let’s stop all this. I’m sick of reading all the ideas on TOGA, Airbus Thrust Levers .. what ever.

The cause of the accident was fear. Fear of being called into the office for a “long” landing. The Captain in question had already been in the office ( not a pleasant experience in EK) once before for a “ long landing’.

The point the touched down.. they could have stopped happily and that would have been that. But because of the stupid “ long landing “ warning they went around.. and because of fear, the Captain was not flying the aircraft but thinking of his future. As go arounds under a 1000 feet require a ASR at EK, the FO was probably thinking .. how wIl this affect my upgrade?

I’m sorry.. in EK and FZ, fear is the elephant in the room that no one talks about.

You are only as good as your last sector.

i don’t know the history of the Captain but I am sure a visit to the office would have been noted in the report.

in fact the report goes on to say.....

The Commander and Copilot FDM data on landings indicated that they never touched down beyond the touchdown zone.

i don’t disagree with your point about fear but it does not seem to be supported by the facts in evidence in this case.

[Uplinker]

Ok ... let’s stop all this. I’m sick of reading all the ideas on TOGA, Airbus Thrust Levers .. what ever..

No, let's not. If you don't want to read other posts about this, you go somewhere else.

[Dropp the Pilot]

How nice - after a long absence we get to see one of those vitriolic, curt, anti-EK rants which are entirely unsupported by the facts. It restores my faith in Australian culture.

[Wizofoz]

How nice - after a long absence we get to see one of those vitriolic, curt, anti-EK rants which are entirely unsupported by the facts. It restores my faith in Australian culture.

I've disagreed with SOPS in the past, but he's right on this occasion. Obviously the event was mishandled- but why go-around at all? That can clearly be seen as a part of a punitive company culture where sense and judgement is banned and blind obedience mandated.

Why on earth would you go-around when you were down to your last 3000m of runway if there wasn't a psychology of fear behind it?

I was there 10 years, most of it in training- SOPS is right on this one.

[swh]

Why on earth would you go-around when you were down to your last 3000m of runway if there wasn't a psychology of fear behind it?


Exactly they went around because they thought they would get into trouble, trouble with the company because of a long landing, and trouble with ATC as they reduce the spacing so much even in conditions that would reasonably cause this sort of issue to require pilots to take early runway exits.

The accident also highlights that the Honeywell system is junk, it only looks at the runway behind them to tell them its a long landing. It should be looking at the amount of runway ahead, aircraft performance, CG, braking etc to determine if it can stop in the remaining distance. Next invention to come out of Honeywell will be a callout that tells you that you have just burnt 10 tonnes of fuel and nothing about the a amount fuel remaining.

A long landing on a dry runway that is 4447 meters in length with a serviceable aircraft in landing configuration must be absolutely terrifying. The margin they had on their inflight landing performance calculation would have been around 2000 m.

So you go around, it is still going to be 50 degrees, the wind profile on final is going to be the same, why do you want to repeat the same all over again when a perfectly good dry long runway is in front of you with enough room to stop twice over.

[tdracer]

With FADECs, there is surely no need for a TOGA switch - you could simply push the levers fully forward, and the FADECs would prevent any excedences.
Not if the FADECs are operating in Alternate Mode (which, BTW, is dispatchable via the MEL)…

I wonder if they are sometimes used as a proxy for the N1/EPR gauges, leading to a lack of scan?

How can they be using thrust lever position as a proxy for the gauges, if they're not paying any attention to the thrust lever position? If the Airbus setup forces the pilot to scan the N1/EPR gauges, how come the Asiana pilot - who was in the middle of an Airbus to Boeing transition - failed to notice the engines were at idle? If you don't monitor the thrust levers, and you don't monitor the gauges, you're asking for trouble.

[tcasblue]

With FADEC, such problems are rare (although they do still happen on occasion due to an obstruction in the aisle stand itself), allowing some pilots to become lazy...

True, we had an RTO because someone placed a cup full of candies on the throttle quadrant, interfering with some of the throttles.

[tcasblue]

Regardless of your opinion of Airbus non-moving thrust levers, this is an aspect they got absolutely spot
Sadly, this can be screwed up as well, we had a very serious incident in the bus where the throttles were pushed forward too the go-around but moved only “one click” forward. There were other issues involved to create the incident but still, if it can get screwed up, it will.

Meanwhile, the EK style accident nearly happened to the same company as well, with tailstrike protection activating before things were finally figured out.

[Uplinker]

How can they be using thrust lever position as a proxy for the gauges, if they're not paying any attention to the thrust lever position? If the Airbus setup forces the pilot to scan the N1/EPR gauges, how come the Asiana pilot - who was in the middle of an Airbus to Boeing transition - failed to notice the engines were at idle? If you don't monitor the thrust levers, and you don't monitor the gauges, you're asking for trouble.

Agreed.
I cannot access the report any more for some reason - I just get error 404 - I did not know the PF was ex Airbus. So I cannot think how PF and PM got into such a pickle over a simple manoeuvre - all you really need is correct power on the gauges and correct pitch on the PFD. No further hypotheses from me on this. SOPS will be delighted.