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vilas
30th Aug 2021, 05:50
This was similar to Hudson river. Hudson case it was in day time but due to time pressure they were not able to maintain the correct approach speed and resultantly the recommended ROD of 3.5ft/sec. at touchdown. They touched down at 12.5ft/sec. Aircraft was written off due that but remained in one piece. This crew had to do it in the night so may be they just found themselves ploughing into water or stalled into water. Besides this aircraft was much older. More details are required.

DaveReidUK
30th Aug 2021, 08:35
Stuka Child

"Where might one find this data?"

FR24 has excellent detailed coverage of the flight, particularly of the last few minutes.

"Also wondering what the attitude of the aircraft was at touchdown."

Given the low horizontal speed and relatively shallow FPA, I would imagine that it hit the water in a tail-down attitude (more so than US1549), hence the fuselage breach.

Magplug
30th Aug 2021, 09:36
Cactus 1549 was a premeditated ditching, albeit with only 90 seconds notice. The aircraft was ditched on a flat-calm, inland waterway in good visibility. The modern construction of the airframe no doubt contributed in some degree to the hull remaining intact. Those factors gave the crew the best chance of executing a successful water landing. Had the crew been presented with the same scenario in open coastal waters, even with a slight swell running, the outcome would have been very different.

I am struggling to recall an accident involving a jet aircraft ditching in the open sea that had a good outcome..... regardless of it's attitude at impact.

Stuka Child
30th Aug 2021, 20:28
DaveReidUK:

I went on FR24 like you said, and the last data point seems to show 114 KTS and 1088 FPM for the rate of descent - not sure where you saw the 150 FPM. Rescuers say that winds at the time of rescue were at 17MPH, so roughly 15 KTS. Even in the scenario where it was all headwind, 129 KTS is pretty slow if they were heavily loaded - hence the high rate of descent at touchdown. If you listen to the audio, at some point you will hear the crew mention they are worried about their airspeed. We will have more information when the report comes out, but I believe they attempted to slow down their descent and stretch the sort-of-powered glide and in the process ended up on the wrong side of the drag curve and plopped her in like vilas said.

As for the sea, rescuers said they were working in 5 foot swells. There is zero way you will break an aircraft in 5 foot swells in a normal ditching.

You can see in the pictures that the nose was shorn off, indicating the aircraft touched down tail-first and then the front section slammed in in a hard secondary impact, similar to Turkish 1951. Even the way the aircraft broke apart is similar. The forces, however, were of a lesser magnitude, and this crew survived the secondary impact.

Magplug:

That is incorrect. Ditchings usually have a good outcome in the sense that the aircraft remains intact, but unfortunately there is often the risk of drowning.

Air Niugini 73 (B737-800) - aircraft intact but eventually sank to the sea bed 100 ft below - one person drowned
ALM 989 (DC-9) - although landed on significant swells, aircraft intact but eventually sank in 5000 feet of water - 24 drowned or were thrown about at impact due to not wearing seatbelts, as the ditching wasn't properly announced
Japan Airlines 2 (DC-8) - aircraft intact, came to rest on the sea bed in the shallows - 0 fatalities
Lion Air 904 - aircraft only suffered damage upon hitting rocks in the shallows - 0 fatalities

So no, the norm isn't aircraft breaking in pieces when touching the water, regardless of water depth or the presence of waves. People think that because the most famous ditching in history before Sully was the hijacked 767 from Ethiopian, which went down off the Comoros Islands. It broke apart due to impacting the water at high speed with a left bank, which caused the left engine to dig in, while also hitting a reef. Of the fatalities, many drowned as they became trapped in the half-submerged pieces of wreckage. More CFIT into water than ditching.

DaveReidUK
30th Aug 2021, 23:15
Stuka Child

"I went on FR24 like you said, and the last data point seems to show 114 KTS and 1088 FPM for the rate of descent - not sure where you saw the 150 FPM."

Impact occurred at 11:44:54Z. Sixty seconds before that, altitude was 150 ft. While RoD increased during the last few seconds, there's no way it reached over 1000 fpm.

Mode S vertical rates are notoriously inconsistent.

sandiego89
7th Sep 2021, 17:50
Stuka Child

3 of those 4 examples would not really be considered "ditchings" ie purposeful/unavoidable water landings as we are discussing here, Air Niugini, JAL 2 and Lion Air 904 all landed short/contacted the water short of the runway, some more than others.

Locked door
11th Sep 2021, 08:25
If they ditched at 115 knots why has the fuselage broken up into three pieces?

Imagine if the Hudson aircraft had done that. Seems to me that the 737 has significant weak spots in the design, the fuselage always seems to break into three with anything other than the mildest of impacts.

I realise this isn’t scientific research, however I know where I don’t want to be sitting. Check out the photos below.

https://www.google.com/amp/s/www.independent.co.uk/news/world/americas/cargo-jet-crash-wreckage-hawaii-b1882137.html%3famp

https://www.flightglobal.com/safety/dutch-reject-notion-of-us-pressure-during-turkish-737-crash-probe/136258.article

https://www.baaa-acro.com/crash/crash-boeing-737-8bk-georgetown

https://www.airlive.net/breaking-a-pegasus-boeing-737-has-crashed-at-sabiha-gokcen-airport/

https://en.m.wikipedia.org/wiki/Continental_Airlines_Flight_1404

DaveReidUK
11th Sep 2021, 08:57
If the Hudson aircraft had gone down in the open sea, it might well have done.

FlightDetent
11th Sep 2021, 10:07
Locked door

The aircraft is built and designed fine. The relevant crash-worthiness requirements are complied with.

Yes, if you slam the airframe too hard it will break at some specific point first. If you crash-open the same type multiple times, it will disintegrate at the same locations across the hull. Really, there is no magic.

It's the most beaten and hardworking type of all aviation history, and there's absolutely no need to be paranoid.

The general consensus is, not surprisingly, that any impact energy consumed during the destructive deformation of materials is on the good side of survival effects as it is not transferred to occupants. As much as this does not prevent the ceiling panel from slicing one's head off.

It seems to be true, I agree, there are specific seat sections where the chances of walking out from a crash are higher than elsewhere. Well, for the Sukhoi at UUEE it worked exactly the other way, and not everyone has the chance to pick 0A/B.

No need to worry about the 737, really no. It would be a pity if, after 30 years of debunking the Toulouse grass-cutter myths and reaching a bit of a plateau there, we succumb to yet another name shaming contest.

vilas
11th Sep 2021, 12:40
FlightDetent

Except, that there was a documentary on Al Jazeera about 737 NG in that Boeing workers had expressed dissatisfaction about fuselage joining process etc. and many NG excursions led to break up of fuselage.
If you compare Hudson river touchdown at 12.4ft/sec as against recommended 2.5ft/sec although damaged still the fuselage didn't breek up.

FlightDetent
11th Sep 2021, 16:02
12,4 * 60 = 744, that's a no-flare landing. Any Boeing could sustain that equally well and it's been tested during base training many times, I'm sure.

But that is not your point, understood. Luckily we have no Airbii or Embraer to compare, hope it stays that way. Although I do think they'd result in less disintegration. Designs that are 30 or 40 years more advanced in stress engineering and CAD application should pass the crash test more gracefully.

Building a theoretical fuselage and wings is not probably black magic, joining them together however could be. The 737 is done the way it is done, it is done well enough for a trustworthy airliner.

Roj approved
11th Sep 2021, 23:35
In regards to this accident and subsequent hull break up vs The Hudson incident.

There are a few things that were very different.

1. It was night - much harder to judge a landing onto a black unlit, uneven surface.

2. 5 foot waves in open water - any sailors or surfers will know the power of the waves, we do not know if the airframe broke up immediately.

3. Airframe age - this is an old aeroplane, that does many short sectors, and has a cargo door mod.

This crew survived a horrific ordeal, as did the passengers and crew on the Hudson.

Would the A320 have survived in the same conditions? I don’t know, and I hope none of us ever find out.

vilas
12th Sep 2021, 04:40
DFDR will show the impact load/ROD only then one will know what happened.

tdracer
13th Sep 2021, 02:09
I rather doubt a 737-200 is going to have a DFDR. More likely one of the old analog tape units - and impact loads/ROD are not likely...

As for the fuselage breaking into three pieces - sorry but that's basically just physics. The strongest bit of the fuselage is the wing box (by a considerable margin since it carries both the total wing loads and total fuselage loads) - that's not going to be the first thing to let go if the fuselage is overstressed. It'll fail in front and/or behind the wing box - so you get the front and rear fuselage sections breaking off from the wing box.
Like I said, basic physics.

hunbet
1st Oct 2021, 14:04
"The National Transportation Safety Board (NTSB) announced that the recovery of a cargo plane that ditched in waters off Kalaeloa (https://www.khon2.com/local-news/ntsb-officials-begin-investigating-cargo-plane-that-crashed-off-oahu/) will begin in October."

​​​​​​https://www.khon2.com/local-news/cargo-plane-that-crashed-off-oahu-soon-to-be-recovered-from-ocean-floor/

BFSGrad
13th Oct 2021, 02:08
NTSB Twitter shows investigators boarding the Blue Horizon to begin recovery operations for TransAir 810.

NTSB Prepares to Recover 50-Ton Section of Crashed Jet (https://www.maritime-executive.com/article/ntsb-prepares-to-recover-50-ton-section-of-crashed-jet)

john_tullamarine
13th Oct 2021, 22:55
That's a pretty heavy -200 ?

Roger_Murdock
2nd Nov 2021, 14:39
https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/800x400/1635863904_c6e4177aa91e3a6d23e40d276708001e6d797770.jpeg
https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/800x400/1635863913_d355c98dbe865e508797b6b068c0ad80fc6922a6.jpeg

From NTSB via Ian Duncan

Roger_Murdock
2nd Nov 2021, 15:22
Full photoset https://www.flickr.com/photos/ntsb/sets/72157719519744779/ and B-Roll: https://www.youtube.com/watch?v=MRMW-rsn--w

tdracer
2nd Nov 2021, 18:13
Based on that amount of damage, they must have hit the water HARD!
That wasn't a Sully style gentle ditching... The pilots were lucky to get out.

hunbet
2nd Nov 2021, 20:11
T/O flaps still set. Yeah it hit pretty hard to rip off the nose gear and everything below the floor beams.

megan
3rd Nov 2021, 04:30
That's a pretty heavy -200 ?Perhaps an allowance for entrained water in the crane lifting capacity.

India Four Two
3rd Nov 2021, 05:29
Interesting video. I'm wondering how did they get the slings attached? ROVs or divers?

megan
3rd Nov 2021, 06:17
The video shows ROV, claw shown with sling and with pilot at ships controls. The linked article says the ship is equipped with ROV.

Pugilistic Animus
4th Nov 2021, 07:23
I think that the chances of survival would increase if the pilots had a seaplane endorsement. When I have time, I contemplate what would I do in the open ocean ditching. . I would probably treat it as a rough water landing and glide on down while remembering to slow down late as late as possible to not let high sink rates develop and hope for the best . Probably wouldn't work but it’s what I do....also, there's excellent advice on ditching in the FAA AIM

Locked door
4th Nov 2021, 08:11
The evidence suggests these guys didn’t perform a controlled ditching with minimum energy, they crashed into the sea while trying to make it to an airfield. They were so, so lucky to survive, had there been passengers there would have been catastrophic loss of life.

Wings off, engines off wings, fuselage in three pieces. Compare that to what’s left after a successful ditching of an aircraft the same size.

RatherBeFlying
4th Nov 2021, 16:38
Sea state likely played a major role in the damage pattern. Sully had the advantage of daylight and confined waters.

tdracer
4th Nov 2021, 20:40
Plus Sully got the APU running so he had full electrical power and all the instrumentation that goes with it.
Still haven't heard confirmation one way or the other, but if both engines went sub-idle, the IDGs would have dropped and they would have been on (very limited) battery instrumentation (which I don't think includes radio altimeter)..

Liffy 1M
4th Nov 2021, 22:26
The wings, empennage and fuselage aft of the break are all essentially in one piece and, in many respects, undamaged. However the aircraft hit, a lot of energy was absorbed such that it broke apart in really just two sections. It will be very interesting to see what the investigation can say about how it impacted the water such that it ended up in this state.

hans brinker
5th Nov 2021, 00:47
Locked door

So, what are the successful ditchings of these aircraft?

vilas
5th Nov 2021, 11:31
Sully's wasn't gentle either. As against recommended ditching of minimum VS, Sully landed around 740ft/mt. That's because of the time pressure his speed went19kts below recommended Vapp and due to activation of airbus alpha (low speed) protection was unable to flare sufficiently. That's why aircraft was written off.

Sailvi767
5th Nov 2021, 13:12
Any airliner that goes into salt water is going to be a write off. Almost certainly the same for fresh water.

FlightDetent
6th Nov 2021, 11:28
I see TE flaps in, or almost so.

Imagine a crew trying to make a field with insufficient thrust, understandably they'd be keeping clean conf. and speed for max L/D. On the other hand, a pre-determined ditching is surely flown at the slowest Vref you could get.

Estimating 210 and 130 kts for the two cases, with an impact weight of 49 t,

the kinetic energy equation gives 270 MJ and 104 MJ respectively.

No need to look any further why the same metal buckles and bends once but breaks and tears on a different day.

The involuntary ditchings discussed above were all at approach speed, to my understanding.

Hueymeister
19th Apr 2022, 11:43
Any more news on cause?

GBO
20th Dec 2022, 20:03
Updated report from NTSB is suggesting a human factors accident.
Crew misidentified the dead engine. Crew reported they had lost #1 engine.

https://data.ntsb.gov/Docket/Document/docBLOB?ID=14846265&FileExtension=pdf&FileName=FDR%20Factual%20Report-FINAL-IntoDocket-Rel.pdf

As the aircraft passed through about 390 ft at 155 knots, engine 2 EPR suddenly dropped to 1.43, while engine 1 remained at its previously set takeoff power. Immediately after engine 2 EPR dropped, the rudder pedal moved to about 5.5 degrees of left rudder, consistent with a command to counteract the adverse yaw of losing thrust on the right engine. The climb paused at 1,000 feet for 25 seconds, then continued to 2,000 ft.

At 2,000 feet, engine 1 EPR reduced to a value of 1.051, which is consistent with idle power in previous flights. It stayed at this value for the remainder of the flight.

Engine 2 EPR also reduced at 2,000 feet, however it continued to be advanced and reduced several times until the end of the flight.

Altitude and airspeed decreased over the next 9 minutes until the end of the recording. At the end of the recording, engine 2 EPR was 1.462 and engine 1 EPR, having been stable since it reduced at 2,000 feet, was still consistent with previous flight idle settings at 1.052.

BewareOfTheSharklets
21st Dec 2022, 09:48
The CVR transcript is certainly illuminating.

https://data.ntsb.gov/Docket?ProjectID=103407

punkalouver
21st Dec 2022, 15:08
The CVR transcript is certainly illuminating.

https://data.ntsb.gov/Docket?ProjectID=103407

Initially identified correctly by the copilot, who was flying, as the #2 engine. Once more stabilized, probably at a reduced thrust setting, the both pilots appeared to mis-identify the faulty engine as the #1(use of EGT for identification was discussed). It appears that the #1 thrust lever was brought back to idle. Therefore, it could have easily been used when maintaining proper speed/altitude became difficult. Even if you think that engine is faulty, you definitely want to try using it when it becomes obvious that you will be descending into the water soon.

BFSGrad
21st Dec 2022, 15:10
“As the aircraft passed through about 390 ft at 155 knots, engine 2 EPR suddenly dropped to 1.43, while engine 1 remained at its previously set takeoff power. Immediately after engine 2 EPR dropped, the rudder pedal moved to about 5.5 degrees of left rudder, consistent with a command to counteract the adverse yaw of losing thrust on the right engine. The climb paused at 1,000 feet for 25 seconds, then continued to 2,000 ft.
Would the rudder deflection have been commanded by pilot foot or yaw damper at this point in the flight?

RatherBeFlying
21st Dec 2022, 17:09
I am reminded of the Kegworth 737 crash where the good engine was also shut down.

​​

oceancrosser
21st Dec 2022, 17:51
Would the rudder deflection have been commanded by pilot foot or yaw damper at this point in the flight?

On a 737-200??? Or any 737 for that matter. Foot.

JanetFlight
21st Dec 2022, 20:06
I am reminded of the Kegworth 737 crash where the good engine was also shut down.

​​

IIRC also the TransAsia ATR72 after T/O at Taipei...bad engine rolling, good engine cut :(

BFSGrad
21st Dec 2022, 22:07
Excerpt from the 2nd captain interview. Epiphany?

Oh, if the number 1 engine is gone, it's not only the EPR. Then you'll get backup information. It's not going to be only from Greg [FO]. You're going to get backup indication to confirm that number 1 is gone. But we didn't get there. We didn't, we didn't get there. You know, right now I think, as I'm sitting here and you're asking me about number 1 thrust lever, number 1 -- number 1, I'm beginning to wonder did we shut down the wrong engine, you know? Because I don't know.

giggitygiggity
21st Dec 2022, 23:08
Is this going to have any imapct on the 737 Max-10 debacle (not that I understand it even vaguely well enough), but isn't the issue they're trying for the ability ignore the mandate on EICAS implementation. I'm an Airbus guy, ECAM or equivalent have identified this far better, certainly far more methodically?

FlightDetent
22nd Dec 2022, 03:29
There has been a case on Airbus where N1/N2 vibration was mistaken for left/right engine designation. Just because of the digit (while squarely showing on-side where the problem actually was).

Engineering HF mistakes out is understandable, but to which extent is it justified?

tdracer
22nd Dec 2022, 17:17
Is this going to have any imapct on the 737 Max-10 debacle (not that I understand it even vaguely well enough), but isn't the issue they're trying for the ability ignore the mandate on EICAS implementation. I'm an Airbus guy, ECAM or equivalent have identified this far better, certainly far more methodically?
Actually, the Kegworth disaster would suggest that changing the flight deck from what the crews are used to might be a bad idea. One of the contributing factors in Kegworth was that on the 737-400 (and -300 IIRC) they'd changed the vibration displays relative to the -200 that they crew was used to. That contributed to the crew miss-identifying the bad engine.
Unintended consequences can be a bitch...

punkalouver
23rd Dec 2022, 01:34
Actually, the Kegworth disaster would suggest that changing the flight deck from what the crews are used to might be a bad idea. One of the contributing factors in Kegworth was that on the 737-400 (and -300 IIRC) they'd changed the vibration displays relative to the -200 that they crew was used to. That contributed to the crew miss-identifying the bad engine.
Unintended consequences can be a bitch...
The Kegworth and transAsia(ATR) accidents involved actually shutting down the good engine followed by an eventual scramble to get it started again. Gpoing fropm memory of the Kegworth report, it appeared that the analysis of the condition of the engines was done quickly by the F/O and accepted by the captain. There is no rush. Just take time and analyze. I suspect that when the engines have been reduced to a lower power setting, it makes it more difficult to identify a partial failure. Perhaps move thrust levers to see reaction on the guages and take your time unless there is a specific reason to be hasty).

It looks like this case is a perfectly good engine that was brought to idle but was still running, and in a position to be immediately used but assumed to be faulty and left at idle. From a procedure point of view, one wonders why they didn't take the time to shut it down if they thought it was faulty. Quite odd.

But on the other hand, seeing as they didn't follow typical procedures and shut down what they thought was a faulty engine, their atypical procedure left them with a big advantage........the ability to use the engine at idle, regardless of whether it was faulty or not. It appears that they thought they had two bad engines. But why would you not attempt to use that engine as things get worse and worse with the GPWS sounding and the altitude and speed decreasing. It would seem that it was assumed that because the engine at idle was in poor shape, it was never considered but one should definitely have in mind that they will take whatever they can get from what is assumed to be a bad engine as it could prevent a crash. Get what you can from both of them in such a situation(and in this case, they would have gotten a bunch of thrust from when they thought they wouldn't get much).

megan
23rd Dec 2022, 05:47
Actually, the Kegworth disaster would suggest that changing the flight deck from what the crews are used to might be a bad ideaThe Captain had a total of 763 hours on 200, 300, 400 but only 23 of those hours on the 400. Copilot 192 total 300 and 400, 53 of those on 400. Report mentions the reduced conspicuousness of the vibration indicators on the 400 and the fact crews didn't have any simulator time on the 400. Haste in shut down, all not helped by high workload associated with the diversion. Gotchas creep out from everywhere.

Report

https://assets.digital.cabinet-office.gov.uk/media/5422fefeed915d13710009ed/4-1990_G-OBME.pdf

Commentary on panel layout

https://assets.digital.cabinet-office.gov.uk/media/5422feffe5274a131400097f/4-1990_G-OBME_Append.pdf

punkalouver
24th Dec 2022, 21:47
Quotes(in black) from a Flight International article based on NTSB information.....

"The first officer, who was flying, replied “number two” – an apparent reference to the right-hand powerplant – and the captain also said, “number two”.

According to the quote above, the captain repeated what the F/O said(unknown if he based his reply on separate analysis). Then according to the quote below, the copilot changed his mind and the captain did as well(unknown what further assessment was made by the captain before he changed his mind).

"According to the transcript, the captain asked the first officer to “read the gauges” to determine which “has the EGT” – the exhaust gas temperature – to which the first officer replied: “It looks like the number one.”The captain then responded, “Number one is gone?”, and the first officer responded: “ gone, yep…so we have number two.”

“So we have number two, OK,” the captain then remarked."

The captain made this statement to the inquiry.....

"The captain told the inquiry that he thought the left-hand engine had the problem, at first, before changing his mind – based on the aircraft’s yaw and roll motion – and telling the first officer that he thought the right-hand engine was the one affected.

But during his testimony the captain referred to the first officer’s having told him that the number one engine, the left-hand powerplant, had failed.

The captain told investigators that the first officer, which whom he had flown several times, “never makes a mistake”, adding: “If [he] says number one is gone, then number one is gone.”

A bit of a conflict in statements but quite the trusting captain. Based on the CVR recording, it seems quite possible that the captain did change his mind based on what the F/O said, instead of analyzing the problem.


This reminds me of the Kegworth accident when it comes to failed engine identification. To quote the report.....

"[i]The first officer also said that he monitored the engine instruments and, when asked by the commander which engine was causing the trouble, he said 'IT'S THE LE ... IT'S THE RIGHT ONE.', to which the commander responded by saying 'OKAY, THROTTLE IT BACK'."

Once again, no detail on what analysis that captain did, but it does give one the feeling that he may have relied on what the copilot said instead of confirming himself(captain was flying). One really should take extra time to identify a partial engine failure, if time permits. the consequences of a mis-identification can be catastrophic. In addition, a partial failure may not be obvious after thrust has been reduced.

FlightDetent
25th Dec 2022, 02:23
My type has a TL indication, commanded EPR target if you will. Already rated a few years when I copied someone's technique to visually observe how that doughnut moves - on the dead engine - as I pull the TL back to idle.

And later added an extra eyeflow myself, to confirm what the remaining good engine is doing AFTER closing the TL, i.e. BEFORE taking the next step of selecting the master switch/fuel shutoff. Which is a pretty universal tool technique.

Once this became a habit, I get stunned at how little is being actually checked by colleagues in the SIM who do the same as I used to (admittedly we always got it correct).

WideScreen
25th Dec 2022, 07:06
Quotes(in black) from a Flight International article based on NTSB information.....

"The first officer, who was flying, replied “number two” – an apparent reference to the right-hand powerplant – and the captain also said, “number two”.

According to the quote above, the captain repeated what the F/O said(unknown if he based his reply on separate analysis). Then according to the quote below, the copilot changed his mind and the captain did as well(unknown what further assessment was made by the captain before he changed his mind).
SNAP......
Once again, no detail on what analysis that captain did, but it does give one the feeling that he may have relied on what the copilot said instead of confirming himself(captain was flying). One really should take extra time to identify a partial engine failure, if time permits. the consequences of a mis-identification can be catastrophic. In addition, a partial failure may not be obvious after thrust has been reduced.
Or so to say, tick the QA items, without checking ? Where did we see that before ? Boeing ('s production) ?

I think, the more the "actions" are physical, the more people are inclined to take things for granted and leave out the "logic" items, since that does require a change in mental attention, from the steam gauges and levers attention, over to check-list booklets. With the whole being more "push-button" oriented, it needs mental attention to what the meaning of the buttons is, and the drivers are already in that mental state to "think" what they are doing.

punkalouver
25th Dec 2022, 12:19
My type has a TL indication, commanded EPR target if you will. Already rated a few years when I copied someone's technique to visually observe that doughnut to move - on the dead engine - as I retard.

Later adding an extra eyeflow to confirm what the remaking good engine is doing AFTER closing the faulty TL. BEFORE actioning the master switch/fuel shutoff. Which is a pretty universal.

Thanks, any chance of more detail on your explanation. It is quite interesting.

H Peacock
25th Dec 2022, 15:43
The Kegworth avoidable accident was largely down to very poor CRM. Do I even recall the captain taking over as PF and taking the AP out!!

The crew were very much system-biased, ie where the AC bleed was fed from; all the (correct) indications were there to be seen on the EICAS, but they erroneously chose to ignore them!

By George
25th Dec 2022, 21:08
There is no EICAS on the 400. The engine instruments also come in two versions, analogue and what I call 'half-glass', the older analogue easier to read in my opinion. With the 200, EPR is the top row replaced by N1 on the 300 onwards. I see wrong identification more than I should in the Sim and rushing is the common cause. Never rely on yaw if the engine is surging and just take your time reading the dials. As in all accidents there were many factors in the Kegworth accident including poor communication with the F/A's.

Looking at the fuselage break in the Hawaii ditching it makes me smile to read the ditching drills in the manual. You can't learn everything from books, sometimes you have to make it up as you go along.

India Four Two
26th Dec 2022, 11:25
The CVR transcript is certainly illuminating.

https://data.ntsb.gov/Docket?ProjectID=103407

The thing I found most illuminating about the transcript was the verbatim nature of it - everything said by the pilots was transcribed. I seem to remember in other NTSB transcripts, non-pertinent conversation was not quoted (asterisk?).

Is this a hint that the NTSB's final report will indicate that the non-operational discussions were a causal factor?

prickly
26th Dec 2022, 11:51
I notice the FAA -NTSB are still using gender specific pronouns, marvellous. Here in the land of wasted opportunity, the ATSB now refer to individuals as they, them or their.

BFSGrad
26th Dec 2022, 16:31
Excerpt from FO 2nd interview:

Q. Is the rudder pressure -- does it take a lot of pressure when you lose an engine to hold it or is it kind of like tiptoe touching pushing rudder?
A. It does in the simulator. But in the airplane, it didn't. It wasn't (indiscernible) that much. I was surprised. I remember being surprised that it wasn't like the simulator.
Q. By not the simulator, I just want to make sure I in my head I have it correctly -- you're saying in the simulator it took a lot of pressure. And in the --
A. Yes.
Q. -- airplane, it did not. Correct?
A. (No audible response)

The FDR data appears to indicate that initially the problem was a partial loss of thrust on the #2 engine, which surprised the FO because the Transair sim training was for complete loss of thrust.

Grummaniser
27th Dec 2022, 12:24
Excerpt from FO 2nd interview:

Q. Is the rudder pressure -- does it take a lot of pressure when you lose an engine to hold it or is it kind of like tiptoe touching pushing rudder?
A. It does in the simulator. But in the airplane, it didn't. It wasn't (indiscernible) that much. I was surprised. I remember being surprised that it wasn't like the simulator.
Q. By not the simulator, I just want to make sure I in my head I have it correctly -- you're saying in the simulator it took a lot of pressure. And in the --
A. Yes.
Q. -- airplane, it did not. Correct?
A. (No audible response)

The FDR data appears to indicate that initially the problem was a partial loss of thrust on the #2 engine, which surprised the FO because the Transair sim training was for complete loss of thrust.
My thought was that the F.O. overcompensated with left rudder, perhaps due to the SIM needing a bootful or perhaps because the #2 failure was only partial, which then caused a left yaw, leaving the CPT with the impression that the left engine had the problem.

xetroV
28th Dec 2022, 11:43
Had a sim session once with the other pilot simulating incapacitation immediately after lift-off, plus an engine failure occurring on number 1 and simultaneous engine fire indication on number 2 (the engine still providing thrust). Yes, a quite unrealistic scenario, but it absolutely helped me learn to analyse the problem first before rushing into action.

hans brinker
28th Dec 2022, 18:58
Had a sim session once with the other pilot simulating incapacitation immediately after lift-off, plus an engine failure occurring on number 1 and simultaneous engine fire indication on number 2 (the engine still providing thrust). Yes, a quite unrealistic scenario, but it absolutely helped me learn to analyse the problem first before rushing into action.

Guess you could hit a flock of birds, one engine failed, one on fire. But losing the other guy is a stretch....

EDLB
28th Dec 2022, 19:03
Shut down the good engine on a twin happens relatively often. So the pilots did a good thing only idling the assumed faulty one. Why did it never appear to them to give the idling engine a shot while they had already called for the coast guard. Task saturation? I would think you firewall all power you have if you go down over an ocean at night. Why stick to a wrong decision making if there is very little to loose if you try the other options? May be the training is not optimal for those situations?

tdracer
28th Dec 2022, 21:01
Looking at the fuselage break in the Hawaii ditching it makes me smile to read the ditching drills in the manual. You can't learn everything from books, sometimes you have to make it up as you go along.

Big difference between ditching during daylight, good visibility, and calm seas vs. night, low visibility, and moderate to rough seas.

That being said, I worked with a guy that - since there had never been a successful ditching of a jet with high bypass, underwing engines - figured we could save a lot of weight and money getting rid of the rafts and all that other stuff since it'll never be needed (this was before Sully - but to be fair the Hudson is much different than open ocean).

BFSGrad
28th Dec 2022, 23:55
Shut down the good engine on a twin happens relatively often. So the pilots did a good thing only idling the assumed faulty one. Why did it never appear to them to give the idling engine a shot while they had already called for the coast guard. Task saturation? I would think you firewall all power you have if you go down over an ocean at night. Why stick to a wrong decision making if there is very little to loose if you try the other options? May be the training is not optimal for those situations?
Appears the idling status of #1 was not due to any conscious effort by the pilots. Both pilots were absolutely convinced that #1 was a dead donk. Therefore in their minds, operating the #1 thrust lever was pointless. Both stated the engine failure shutdown checklist was started by not completed. From the interviews, unclear who split the thrust levers. FO claims he operated TLs together. Captain claims he operated only the #2 TL, with the status of #1 TL unknown to him because it was too dark to see.

BFSGrad
17th Jun 2023, 00:08
Final report probable cause: The flight crewmembers’ misidentification of the damaged engine (after leveling off the airplane and reducing thrust) and their use of only the damaged engine for thrust during the remainder of the flight, resulting in an unintentional descent and forced ditching in the Pacific Ocean. Contributing to the accident were the flight crew’s ineffective crew resource management, high workload, and stress.

N810TA Final Report (https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103407/pdf)

oceancrosser
17th Jun 2023, 02:38
Those darn third world pilots, can’t even identify a failure…oh wait!

Boeingdriver999
17th Jun 2023, 07:04
Sully didn’t flare the 320 into the Hudson; he had full back-stick for the last 20 seconds and relied on Airbus protections to prevent a stall and minimise airspeed.

FlightDetent
17th Jun 2023, 07:55
Sully didn’t flare the 320 into the Hudson; he had full back-stick for the last 20 seconds and relied on Airbus protections to prevent a stall and minimise airspeed.Suboptimal technique following a black swan event. Many happy that the top priority of picking a safe and reachable landing spot was executed strikingly well.

The difference between losing one or two on a twin lies with the training and proficiency requirements of the TR/licence.

Boeingdriver999
17th Jun 2023, 13:29
Well that report makes for pretty depressing reading. Interesting that no mention of the crew’s training record is made so I guess not relevant.

Also, why oh why is it so hard for Americans to just say “Mayday”? The low quality of US radio procedures contributed to this accident. Imagine if it had been a passenger flight?

Shaking my head in disbelief 😳

BFSGrad
17th Jun 2023, 19:45
The low quality of US radio procedures contributed to this accident. Imagine if it had been a passenger flight?Per the CVR transcript, within 10 seconds of the engine failure, the FO correctly identified the failed engine and the captain correctly acknowledged which engine had failed. This was before the ATC comms “project” began.

I agree that U.S. aviation comms have room for improvement but don’t think the struggle with comms during this accident was contributing.

First_Principal
17th Jun 2023, 22:58
As with many such events there are various things one could focus on, however I'm interested in two things:

(1) ".... while the airplane was climbing through 700 ft and noted an issue with the left engine, so he [the captain] decided to immediately return to the airport. The captain reported that the company chief pilot criticized him for returning to the airport without performing the relevant abnormal checklist."

While I get that checklists are there for a reason I posit that blind adherence to said list(s) may sometimes get in the way of flying the 'plane and optimal crew/passenger safety? It would seem to me that, notwithstanding the flawed identification of the failed engine, had an immediate return to land occurred it's likely there would have been a better outcome, and that the CP's admonishment of the captain has some bearing on this outcome.

For the avoidance of doubt, this is not a criticism! I'm rather more interested in people's views re the rigid adherence to checklists following EFATO close to the originating aerodrome and when immediate return is possible.

(2) In the same vein, there are many instances of miss-identification of failed engines, Kegworth being one of the more obvious ones. When I did my training for multi-engine multi-crew operation we spent a lot of time on this very issue because of the lessons taught to us by such past events. However the issue, clearly, continues to raise its head.

To that end I posit whether it is better to shut down a supposedly failed engine, or in fact to immediately advance all throttles (if needed to keep flying) and continue to fly the aircraft to touchdown?

Obviously this is germane to partial or even complete loss of power on one engine only, and I recognise that there is risk to this strategy along with the obvious benefits of correct identification, however with particular regard again to EFATO close to the originating aerodrome, and the time taken up + risk of things going wrong during the identification process etc, I question whether there might be a better/simpler way to address such events?

FP.

Boeingdriver999
18th Jun 2023, 06:58
What I think this incident shows is that EFATO or engine failures in general should not be rigidly flown at V1 with a bang and total loss of thrust. Having them occur at some point will force pilots to engage the grey matter and actually think about the problem - like you say First Principal; sometimes it might be better to continue to touchdown. If I’m fully stabilised at 500ft into my home base, CAVOK and an engine winds down would I do a go around or just continue to land? I know what I would do.

BD

Chu Chu
18th Jun 2023, 12:09
As an SLF, it certainly seems illogical to conclude you have two malfunctioning engines and try to continue flying with only one of them.

Boeingdriver999
18th Jun 2023, 13:08
As an SLF, it certainly seems illogical to conclude you have two malfunctioning engines and try to continue flying with only one of them.

An insightful and thought-provoking comment.

Orange future
18th Jun 2023, 16:02
My first listen to the audio recording of the incident.

I didnt know wether to laugh or cry at the R/T back and forth.

I suspect the amount of time spent (mis)communicating on the radio was at the very least a contributing factor to what would have become a single pilot operation.

But at least the "trucks rolled"!!!

FlightDetent
18th Jun 2023, 21:55
If rigid adherece to a NNC (pleonasm, BTW, not-non-adherence?) is what prevents the crew from rushing themselves 6 feet under, then let the flogging begin preemptively I say.

A NNC shall be performed from the beginning, until the end, in the listed sequence, without skipping any items.

Shouldn't be that hard BIG-BUT-HERE: each of us needs a role model to show him how to walk the walk and work the work all the way to the full mile. It still takes a pro to mentor a good pilot out of a talented licence holder.

EDLB
19th Jun 2023, 06:27
Should be an important task for the FAA to figure out, why the two in row 0 never tried to open the throttle of the other idling engine, when the in their mind "good one" could not keep altitude.
Compared to swim they cold hardly loose. So why both where so task saturated that the simple solution never occurred to them.
They did the first right thing and did not shut the engine down, as other did before and tried to relight it in vain. They where so close in saving the night.
Easy to say from the arm chair, but there is something to learn here.

fdr
19th Jun 2023, 09:58
Should be an important task for the FAA to figure out, why the two in row 0 never tried to open the throttle of the other idling engine, when the in their mind "good one" could not keep altitude.
Compared to swim they cold hardly loose. So why both where so task saturated that the simple solution never occurred to them.
They did the first right thing and did not shut the engine down, as other did before and tried to relight it in vain. They where so close in saving the night.
Easy to say from the arm chair, but there is something to learn here.

The point that the cognitive error occurred is identifiable in the CVR, the PIC verbalises the failed engine as #1 whereas the FO had previously determined #2 to have failed. The PIC had assumed PF just before this, and it appears he had made a thrust reduction, and had brought #1 back around this time, and had a cognitive slip. The point of opening up any thrust lever would have saved the flight is valid, the problem is the crew are fighting a confusing SA condition which adds stress to their processes, and that reduces the bandwidth either pilot had to do a simple reasonableness assessment. It is possible to lose two engines, it is not likely, and it is far more likely for a crew to select the wrong engine as the cause of their problems. If the energy state is decaying, adding any lever tooth mix of more noise can only be beneficial.

The CVR is not pretty, the NTSB is making a fashion statement with leaving the complete conversation in the transcript, it should be a learning point on the concept of policy, practices and specifically reduction of extraneous activity in critical phases of flight. While it reads polly, it is closer to what is observed in many operations when undertaking IOSA audits. Humans act as humans do.

Boeingdriver999
19th Jun 2023, 11:09
I agree that by publishing the full CVR they are saying something. Why they can’t state that the crew were lacking any sort of discipline I don’t know.

They were talking about anything but the operation the entire time and the interaction between the two pilots and ATC was crammed with extraneous verbal diarrhoea which only added to workload/stress leaving no cognitive capacity to deal with the ONLY thing that mattered.

Like I said; it’s cringe worthy stuff and coming from the US is just embarrassing.

Locked door
19th Jun 2023, 13:24
Sounds pretty standard for US ATC RT.

EDLB
19th Jun 2023, 17:02
If you read the CVR transcript, https://data.ntsb.gov/Docket/Document/docBLOB?ID=14847557&FileExtension=pdf&FileName=DCA21FA174_CVR_Release-Rel.pdf
the most important item, validation the faulty engine, gets the least amount of attention. They spent 4 minutes on RT after identifying the true defective engine and after the RT they stick to the wrong one.
On a jet you don't face much of drag problem of a faulty engine, so no need to shut down anything quick unless on fire. That part they did right. And before ditching try anything which can increase the noise level.
Simple with 20-20 hindsight from the armchair. The question remains, why did they not go back into problem identifying when the assumed good engine could not keep altitude?
They had 4 minutes from realizing that to ditching. 141.10 to 145.17

hans brinker
20th Jun 2023, 00:13
If you read the CVR transcript, https://data.ntsb.gov/Docket/Document/docBLOB?ID=14847557&FileExtension=pdf&FileName=DCA21FA174_CVR_Release-Rel.pdf
the most important item, validation the faulty engine, gets the least amount of attention. They spent 4 minutes on RT after identifying the true defective engine and after the RT they stick to the wrong one.
On a jet you don't face much of drag problem of a faulty engine, so no need to shut down anything quick unless on fire. That part they did right. And before ditching try anything which can increase the noise level.
Simple with 20-20 hindsight from the armchair. The question remains, why did they not go back into problem identifying when the assumed good engine could not keep altitude?
They had 4 minutes from realizing that to ditching. 141.10 to 145.17

If they had focused on engines as much as they did on female pilots they would have easily identified where they went wrong.

KRviator
20th Jun 2023, 01:28
Am I the only one who is wondering about the Captain's experience with engine failures? From the report:
The captain reported that he had experienced about five engine failures while working at Rhoades Aviation. One such failure occurred about 3 to 4 months before the accidentWTF are they doing there such that the Skipper has a half-dozen actual failures under his belt before he went for a swim? Most crew will go their entire career without having a genuine engine failure outside the box. Precautionary shutdowns, certainly, but genuine hard failures? And this bloke has had 5 before this one - and that's with one company?!? Granted he's got a swag of hours, and I cant see from the report how long he's been employed by Rhoades, but still.....

AerocatS2A
20th Jun 2023, 06:02
About 5, in other words he’d lost count.

Boeingdriver999
20th Jun 2023, 15:33
Orrrrrrr…. Bear with me…… he was unaware of what a failed engine looked liked?

Couldn’t possibly be true…

Hogger60
8th Jul 2023, 22:44
From the NTSB report:

"The NTSB considered whether fatigue played a role in the captain’s errors, but the evidence was inconclusive." and "The NTSB also considered whether the first officer’s errors were due to fatigue. Even though the errors that the first officer made were consistent with the effects of fatigue, the evidence supporting fatigue was inconclusive"

The Captain had worked 20 back side of the clock legs in the previous 3 nights, But the NTSB couldn't determine if fatigue was a factor? WTF? Of course it was a factor. Fatigue is the number one killer of crews and pax, especially for back side of the clock flying Freight Dogs.

Equivocal
8th Jul 2023, 22:50
It's probably fair to guess that both crew members were fatigued, the statement suggests that the investigators could not confidently state that it affected the crew actions and outcome of the flight. Would the crew have behaved in the same way if they were positively well-rested and at the top of their game (from the perspective of cognitive capabilities)?

Hogger60
8th Jul 2023, 23:08
Having done way too much of this type of flying hauling both pax and freight, i know that if I had flown the schedule that they (especially the captain) had flown, that my cognitive capabilities would be significatly impaired compared to my well rested sefl.

Here is what the FAA said about it, in FAA Circular 117-3, which "was developed to demonstrate acceptable methods of compliance with Title 14 Code of Federal Regulations (14 CFR) part 117, § 117.5, Fitness for Duty".

"Fatigue is characterized by a general lack of alertness and degradation in mental and physical performance. Fatigue manifests in the aviation context not only when pilots fall asleep in the cockpit during flight, but perhaps more importantly, during the task-critical takeoff and landing phases of flight. Reported fatigue-related events have included procedural errors, unstable approaches, lining up with the wrong runway, landing without clearances, and poor decisionmaking."

Stress has the same affect, but adding fatigue to the equation will magnify any stress related congnitive impaiment. I can only speak for myself, but I know that I am much more at the "top of my game" if I am well rested.

carpi
31st Aug 2023, 01:31
I agree that by publishing the full CVR they are saying something. Why they can’t state that the crew were lacking any sort of discipline I don’t know.


Of course, during taxi conversations are supposed to be limited to topics required for the safe operation of the flight, which the NTSB have chosen to ignore here. The captain certainly seemed emotional, and neither of them were probably in the best mental state to handle an engine failure, especially given the conversation they'd been having not two minutes before it occurred.

It is indeed interesting that the NTSB have chosen to sweep this under the carpet. I wonder if it would be different if they'd been discussing, say, soccer, rather than the captain's apparently rather extensive list of grievances with one of his co-workers.


As part of the Safety Board’s accident investigation process, the flight crew was
invited to review the CVR transcript and suggest corrections or additions. They
declined the invitation.


I wonder why :p

Uplinker
1st Sep 2023, 09:56
I agree that by publishing the full CVR they are saying something. Why they can’t state that the crew were lacking any sort of discipline I don’t know.

They were talking about anything but the operation the entire time and the interaction between the two pilots and ATC was crammed with extraneous verbal diarrhoea which only added to workload/stress leaving no cognitive capacity to deal with the ONLY thing that mattered.............

I have read most of the report and the CVR transcript, and I agree.

From the report, this Captain was clearly not suitable to be a Captain. Although he sort of generally did what was required, he obviously did not do everything, did not look at details, and his mind was not focussed on the flight. During cockpit prep, there was a very long diatribe from the Captain about another F/O and full and free control checks, which was not appropriate.

Then during the emergency, there seems to have been a complete lack of procedure. I don't know the B737- 200 SOPs or checklists, but surely there must be a section to correctly identify a failed engine - using all the indications and all the engine gauges - and apply max continuous thrust to the good engine? Or wasn't this a procedure in the - 200 days?

From the start of the CVR transcript, this Captain was not being methodical, and he was not focussing on the task at hand. All that stuff about another pilot was irrelevant and a distraction which would have been best left for the hotel or the transport after their duty had finished.

During the emergency, the Captain accepted the F/Os word about the failed engine, but then somehow managed to swap that over in his head to the other engine. Unfortunately, the F/O did not correct him on this - I cannot think why, unless he too was overwhelmed by the situation.

There seem to be similarities between this accident and the UK Kegworth accident - both misidentifying a failed engine in a B737 and crashing with their one good engine at idle. Perhaps Boeing urgently need to review their engine fail procedures and SOPs - especially in the B737 - Classic and the B737 - Prehistoric.

But how did this Captain pass his recurrent Sim checks with his general lack of procedure and lack of attention to detail ? He was once pulled up for not following checklists, but that seems to have been about it.

I have always had doubts about airlines checking their own pilots in the Sim. Once, as PM in the Sim; I personally witnessed a new manager to the company 'handle' an EFATO a bit like this - vague, loose and not following the SOPs etc., although he did keep control of the aircraft. I thought to myself, oh dear how embarrassing, there will be words and he will have to do that all again - (had I not followed the prescribed procedures, I would definitely have been torn off a strip) - but amazingly, the company TRE said to him Yes.......that's all fine !!

As well as most problems in a Sim being blamed on the F/Os, I have personally seen sub-optimum PIC performance being nodded through, especially when a manager is being assessed by a TRE who is junior to that manager, but also a senior pilot being assessed by a TRE technically junior to them.

In terms of CRM, I got the impression - from his very short replies - that this F/O was wishing that the Captain would shut up about the other F/O, and just had his head down trying to get on with the flight - but he did not know how to make the Captain shut up. Later in the flight, the F/O says fly the plane please, or pull up please. Please ?? No need for "please" in an emergency. That suggests to me that the F/O felt he could not control the Captain until it got to the point when the F/O became fearful of a bad outcome, but even then he could not bring himself to directly order the Captain.

In CRM, we are shown accidents and CRM failures, but in my experience, F/Os have never actually been taught how to 'control' a Captain. Some know already but others don't, and it is not easy to override a difficult Captain, or make them behave in a cockpit during a flight. I have had to do it twice, (and once in a restaurant), with stern words, and it was not easy.