View Full Version : A350 pilot startled by windshear alarm

15th Jul 2021, 16:02
French investigators have detailed how a French Bee Airbus A350-900 sharply deviated from the missed-approach pattern at Paris Orly, when one of its pilots was startled and temporarily incapacitated just after an unexpected windshear alarm.
Aviation Herald article (https://avherald.com/h?article=4d39c0fe&opt=0)

15th Jul 2021, 16:37
Descended to 1200’ msl and 290 knots.
Who is allowing this level of incompetence to be in control?
Truly worrying.

15th Jul 2021, 16:39
Having two extra pilots on the flight deck did not seem to help.

15th Jul 2021, 19:36
I guess all that CRM, Type and sim training didn’t work. The fellow flying didn’t know that the autopilot was disconnected even though he was the person who deselected it? The Capt was basically flying solo when he took control after the overshoot.

15th Jul 2021, 20:57
This looks like a great argument for non-manned cockpit

15th Jul 2021, 21:31
This is the product of today's zero to hero flight training. They can program the crap out of the box but can't really fly airplanes all that well. AF447, OZ214 are only two examples of incompetence in the cockpit. United Airlines is on record saying their pilot hiring will prioritize race and gender over flying experience and qualifications. The FAA and international counterparts have lost all credibility. Scary times ahead.

15th Jul 2021, 21:34
its the future, like it or not
we should all just man up and face it

15th Jul 2021, 22:18
No pilots to startle if there’s no pilots in the flight deck to begin with, amirite?

15th Jul 2021, 22:38
no pilots in flight deck and no flight deck either, technically...

Banana Joe
15th Jul 2021, 22:50
That's a lot of fiddling on the FCU so close to the ground after a go around, when a simple pitch and power datum to quickly recall would have made it easier. But I am not qualified on any Airbus so I stand down from further commenting on this.

But maybe I am wrong, I am not trying to Monday quarterback this. If it happened to them, it can happen to me and anybody else as well.

Banana Joe
15th Jul 2021, 22:52

You don't know the background of the pilots involved in this event. In that company there is a high number of former Air Force and Navy pilots. Far from the zero to hero flight training program you allude to.

15th Jul 2021, 23:29
This was an alert to wind shear ahead which simply required a normal missed approach, rather than a wind shear encounter which requires memory items to be applied. The startle effect in an actual encounter is far greater and requires the aircraft to be accurately flown manually with the co pilot in the loop calling out the wind so they know when they can resume normal flight.

AUTO TCAS is available on newer Airbus aircraft, perhaps wind shear needs an automatic response from the aircraft as well. This isn't what I would expect to see from a crew in charge of any commercial jet, let alone an A350.

16th Jul 2021, 00:01

Don't think I've ever seen anyone say it won't happen in the future. But it's not going to happen with today's technology, or anytime soon in my opinion.
It will equire true AI to completely replace pilots, once we have true AI all jobs can be done by machines

16th Jul 2021, 02:16
In that company there is a high number of former Air Force and Navy pilots.

Not necessarily a good combination for a commercial airliner. Cockpit gradient can be influenced by a carry over of military culture. After a brief skim of the AvHerad article it looks like the F/O was still trying to control things after the Captain took over. Startle effect and poorly handled go arounds are nothing new and unless there is a clear statement of who is control then you have two pilots trying to recover the situation. In this case there was a third pilot who was talking to the F/O. Eventually the the Captain said "everyone silent" which seemed to restore order. The airline I am with has been using the sim to develop strategies to overcome startle effect and to look at the physical reaction a person experiences when faced with an unexpected event. In the report it is labelled as cognitive incapacitation. This is not limited to Airbus products, there have been plenty of examples of mishandled go arounds in Boeings.

Anti Skid On
16th Jul 2021, 05:56

Can you provide the evidence of the United statement or are you making this up?

16th Jul 2021, 07:33

Nick 1
16th Jul 2021, 07:57
Probably another case of playing piano on Airbus mcp ...

16th Jul 2021, 08:01
Well they are going to have to doorknock to find them. The issue is that flying is not attractive as a career except to dumb ass white males. Don't ask me to scientifically prove it but the fact that most pilots in western based airlines are white males is not because there is some discriminatory process, in fact aviation would have to be the least discriminatory as if you have the license and the hours and a pulse then you are all they want. The simple truth is females tend not to be attracted to the pointy end. There does not seem to be any shortage of female ATCers so aviation does attract females just not into the flight deck.

16th Jul 2021, 08:08
There are procedural lapses and psychologists are having a field day. Sudden wind sheer warning in normal weather may cause a surprise but causing cognitive incapacitation is not very digestible. Then what wil happen in Hudson case, unreliable speed or in sever upset is unthinkable. The capt who was PM suffered from automation dependency. The AP had not tripped but was disconnected and they forgot. Normal principle is when you dial something on FCU you confirm appropriate aircraft reaction. That's what you do in EMER DES, TCAS or GPWS or even turning to avoid weather. This is a case of automation dependency which develops in time and degrades the scan and people get caught. This is what happened A320 Bangalore, B777 SFO, A321 in Islamabad. In first two they blindly believed in ATHR and allowed their speed to drop badly and in Islamabad the capt took for granted heading mode and dialling in NAV mode till Hdg went past 180, then on sudden realization pulled heading, the aircraft turned shorter way into the hills. So after AF447 A350 has automatic unreliable speed change over, it has automatic EMER DES, auto TCAS. So next will be automatic wind sheer manoeuvre.

Mr Optimistic
16th Jul 2021, 08:09
[Pax]. 'The captain had just put his hand on the sidestick when the copilot probably extended the speedbrakes without calling this out'

The copilot, confronted with the surprise effect in connection with the unexpected triggering of the predictive windshear warning, the change in the rate of work and the increased workload was then “absent” for a few minutes.

Well one or the other. Is there a role for speedbrakes in a windshear go around? [Pax].

16th Jul 2021, 08:13
This simply needs better training and stricter testing of pilots. The problem is arising because training and testing has been cut too far.

AI would cost billions to develop, billions which should be spent on better training. AI can't deal with severe electrical failure or fire or crew problems or ramp problems or passenger problems, so we are still going to need pilots. So let's train them properly !

At every SIM, each pilot should have the opportunity to practise 5 x go-arounds, 5 x OEI go-arounds, 5 x wind-shear, 5 x initial EFATO, 5 x crosswind landings, 5 x TCAS, just from the handling and initial actions point of view. Manual control without FD's where possible.

Each practise should have the five attempts consecutively, so the candidate can learn from their own mistakes and improve and refine their actions each time. Also every SIM should include unreliable speed and partial instrument panel flying.

Dull, and maybe even boring, perhaps, but we would all benefit from the practise.

Check Airman
16th Jul 2021, 08:31
Banana Joe

Does the specific background really matter that much? If you spend enough time doing nothing but staring at the FD, your skills will atrophy.

16th Jul 2021, 09:25
The incident is not about not knowing how to go around but about PF going berserk after hearing WIND SHEER and PM after taking over forgetting to follow up on FCU selections. All the billions will be wasted if this is going to happen. Simulator cannot produce startle unless perhaps give them a go around and cause some loud sound of explosion with blinding flashes of lightning. But they are likely press emergency freeze and run out. Instead of coming out with such conclusions it's better to stop accident/incident investigations and accept that they will happen and move on. Because for every pilot error some human factor is flashed as an epitaph or an obituary and every few years same human factors keep causing similar incidents
Only answer for human factors appears to be is not to have human presence.

16th Jul 2021, 11:17
Banana Joe

When he retired the skies became marginally safer!

16th Jul 2021, 11:27
Hi vilas, I think you've made my point for me. Because neither PF nor PM were practised enough, this wind-shear event caused them both to panic and do the wrong things, and not do some of the right things.

Had they been sufficiently practised, they would have smoothly performed the drill, both PF and PM working together.

The "startle effect" is an overused excuse. Pilots are, (or should be), trained for and have practised all the memory drills and will have performed many of the QRH drills, so there should be no startle effect.

16th Jul 2021, 11:57
As a mere occasional fair-weather well-rested leisure pilot, I wonder how much "after a flight of more than 11 hours" might have contributed to the incident.

16th Jul 2021, 12:22
Double crew, so only max 5 hours in the seat

16th Jul 2021, 13:27
This is just bad handling of an aircraft, pure and simple. Such incidents need genuine pilots, as the term defines.

Now the eternal question is why there were none present and how to remedy the situation.

In my humble opinion the remedy is only training and experience by exposure. But REAL training and not the actual placebo sim scenarios everyone can look into and prepare beforehand. They only please regulations but not real life. Pilots need to regain (or worse: aquire) piloting skills again.
The basic skill required here is: AP/AT off, wings level, pitch + power, then control the speed ….. It’s commonly called flying.

I don’t like the cries for another automatic feature. They can fail to engage, the AP can just throw it back to you because it does no recognise any valid mode or the AT can be engaged but refuses to act etc. etc. In all those cases it’s back to square one, meaning YOU will have to FLY it all over again.

I don’t like the cries for more drills or memory items. There are too many already. Quite often they are somewhat contradictory and more often than not they are prone to changes by rocket-science blessed chief instructors.

In case of confusion or startle, the human being is mostly only able to repeat two or three very simple, trained actions, which again is commonly called flying, but not the myriad of brilliantly crafted multiple step procedures on the 50+ pages in the QRH. They can be skilfully memorised and regurgitated, but it’s way more difficult to apply them correctly when needed. QED.

Nick 1
16th Jul 2021, 13:47
@Uplinker , there is no time in today sim session to practice five time in a row , as you probably know , is the regulator that want the pilot be trained at minimum level . “ They will learn on line training “ or “ They will learn on line flying “ is the mantra.
And then you end up with a released on line cadet asking where to look.
Yes many nice terminology , evidence training , competence training , but the fact are that if an instructor push for more simulator time , nine times out of ten will be indicated as “ bad apple “ from the management . Or we wanna talk the fact that , always the regulator , want the new generation of pilot be trained to Upset Recovery ( in an airliner ) when it is not on syllabus to expose the cadet to a spin or even a full stall during basic training .

16th Jul 2021, 19:10
The whole problem starts with basic flying training, degraded over the years, including stall recovery (eliminated from many syllabus), introduction of the MPL (basically saves airlines money at the cost of what they view as an unnecessary skillset), and cost cutting everywhere else, from Sim time to fuel uplift justification... everything is now the bare minimum because profit trumps everything.

16th Jul 2021, 19:32
For Airbus pilots most of whom retire without experiencing alternate/direct law routine UPRT training is a waste of time. AF447 wouldn't have happened if the crew was emphasized even in a classroom that in alternate law never pitch more than five degrees and just manage bank. The aircraft is envelope protected unless it enters a storm or something unusual attitude is not possible. Instead the simulator should have the ability to cause drop in speed or FD inaccuracies which will improve scan and promote better awareness.

16th Jul 2021, 19:47

If pprune is a place we can speak freely without implicit woke censorship, can I observe the French have a record of basic handling failures of perfectly serviceable aeroplanes, stretching back decades. Pinning down what it is, is awkward, but the tough questions need to be asked.

ATC Watcher
16th Jul 2021, 19:48
The full BEA report ( avail on their web site in French) gives a slight different story .

Fatigue ; not a factor they say although departed SFO 3h late . each crew got sleep rest during the flight and good rest night before. .
No young MPL in there , . F/O PF : 45 years old, ATPL 8600h of which 1200 on A330. Capt PM : 41 years old , ATPL 8000 h 2000 on A330/350 of which 600h Capt.
Relief pilot : 50 years old ATPL 11.700h . 3400 on 330/350..
They just forgot ( all 3 ) to notice the AP was disengaged during the Go around,, which led to a sequence or errors and incidents including maneuvers following a loss of separation with a departing aircraft .
No CVR was available.
Actual windshear highly unlikely considering the weather and being after sunset. , not reported by anyone before or after .

16th Jul 2021, 19:51
I’m puzzled as to why there was any startle factor. The METARS prior to and during this arrival would have alerted me to the possibility of Windshear on approach (maybe even the ATIS stated it). I would have been self briefing (revising the QRH memory items) and later formally briefing the actions I/we would take in the event of a Windshear on final approach. Threat, error, management (TEM).

16th Jul 2021, 20:10
No CVR was available.And why was that? Sorry don't read French, although some things obviously come to mind.

ATC Watcher
16th Jul 2021, 20:53
They do not say only this note :Note: The following information is mainly taken from the flight data maintenance recorder, witnesses testimonies, radio communication recordings and radar data. The CVR was not available.

16th Jul 2021, 21:53

Most pilots will never experience an engine failure - and far fewer will ever experience an engine failure during takeoff/initial climb. That's why it's so fundamentally important that it be trained for - because if you have the bad luck of it happening to you, you only get one chance to get it right.

17th Jul 2021, 05:09
Engine failure was indeed a rare occurrence till PW GTF experiment. Although I liked the innovation, in India it produced an engine shut down almost every five weeks before it settled down. Also engines are not specifically protected against birds, FOD etc. The point about UPRT is different. The airbus is specifically designed to stay within the envelope. That's not the case with unprotected aircraft where the possibility always exists. Giving more handling in degraded modes like alternate/direct law will serve the purpose. Stall becomes a possibility in alternate law stall recovery is already mandatory part of training.

ATC Watcher
17th Jul 2021, 06:25
As to Simulator training , the BEA report says they had a lot, and interestingly mention this :During one of the simulator sessions, the CDB simulated a pilot incapacitation on takeoff as a PM. It turns out that the PF co-pilot for the session was the one in the incident
The report has a good analysis of the incident , makes comparisons with AF447, mentions the BEA 2012 recommendations made to EASA on startle effects , and add new ones asking to take into account of the high climb performance of modern twins when designing missed approach procedures (in ORY : complex, low altitude and a turn ).
The report should be later in English I suspect.

ferry pilot
17th Jul 2021, 07:09
As LP Hartley so aptly put it, “ The past is a foreign country. They do things differently there.” In aviation one of those things was the acquisition of experience, mostly bad, obtained the hard way with everything on the line. You can’t train for it, simulate it or acquire it in a world that has ironed out most of the wrinkles that made pilots wary and cynical and competent in a crisis. Today, better airplanes, technology and systems don’t make better pilots but they do make flying safer. Pilots are not what they were in the past because they very seldom need to be. That is a good thing, even when it does not appear that way.

17th Jul 2021, 07:25
The Pratt GTF not withstanding, engine failure has been a less than one in 100,000 hour occurrence for some time - and during takeoff even less. Since the typical pilot flies ~1,000 hours/year, it's unlikely to occur during any individual pilots career. The problem is that if it does happen, you only get one chance to do it right or you, your aircraft, and everyone on board becomes headline news (and not in a good way).
Flying an Airbus without envelope protection may be extremely rare, but if it happens and the pilot doesn't know how to deal with it, it's going to be very, very bad day for all involved.
Unless it can be shown to be a "10-9 event" (for certification purposes, that means it statistically won't happen during the service life of the aircraft type), the pilots better know how to deal with it.

More to the subject at hand, I'm still struggling with the idea that a properly trained, professional pilot could become "incapacitated" by an unexpected warning. Given that warnings are seldom "expected", a pilot that becomes "incapacitated" by an unexpected warning has no business sitting in the row zero seats.

17th Jul 2021, 09:06
@Nick 1, yes, and a lot of simulator time is wasted. LOFT exercise ? LOFT is what you do on line every day, with a hydraulic or fuel leak thrown in. Why waste hours of precious SIM time doing those - they are for command courses not recurrent SIM exams.

We cannot practise the handling involved with a OEI manual go-around, (no FD's), or wind-shear etc. on the line during our everyday work. The only time available to practise critical manoeuvres and drills is in the SIM.

A concert violinist can practise with their instrument every day and work on tricky passages over and over until they can play them almost without thinking about what they are doing. Pilots cannot do this. We cannot take the aircraft home or use the SIM by ourselves to practice. We have to do it in our armchair or using a cockpit poster. I was not even allowed to use the "cardboard bomber" * in my own time at a previous airline to practise drills on my own. Oh no, said the managers, we cannot allow you to use it. :mad:

If pilots only experience doing a drill every few years, then it is hardly surprising that stupid, unnecessary incidents and crashes result when they get a drill wrong that they haven't flown for ages.

Motor programs take time and multiple repetitions and regular revision to become stored in our memory. Doing something once or being shown something once does not work.

The "answer" some say is to remove the pilots and have AI. Fantastic, what could possibly go wrong?!. So we and our families will get into an aircraft that taxis and flies by itself until one day, something that the programmers never thought of or a sensor that goes wrong causes an awful accident - like the autonomous car that "saw" the plain side of a large truck across its path but assumed it was the sky, so instead of stopping, it carried on and drove straight into it...........

There have been so many accidents and incidents involving basic handling recently, that I think the current training and SIM strategy of airlines is badly flawed. Let's train pilots properly and give us the chance to regularly practise the critical manoeuvres.

* For those who might not know, a cardboard bomber is a mock-up of the aircraft cockpit, with photographs of the switches and dials printed on cardboard sheets and placed in the correct positions to resemble the real cockpit. Pilots can use cardboard bombers to learn and practice drills, and the physical actions and sequences involved.

17th Jul 2021, 09:13

You are like the child in the story Emperor's new clothes. You are not súpposed to say this. For every simple pilot error due to lack of skill, lack of knowledge of the system or poor decision making as an expert you are supposed to throw up some outlandish human behaviour theory to be counted as an expert. Inquires are not supposed to apportion any blame but to find root cause which off course must always be outside the cockpit. Ironically on another thread there's discussion on experiment on A350 long haul flights with single set of crew, one pilot in cockpit and the other one in crew rest. All pilots feel that's dangerous and two must be in front. While as we see Aircraft incidents/accidents happen with two, three or even four in front. In a A320 ferry the deadhead crew also came to cockpit four of them indulged in interesting conversation nobody monitored the aircraft. Due to wind change speed hit VMO, one pulled the speed brake the other pulled the thrust lever disconnecting the ATHR which was reengaged but speed brake was forgotten so speed going south and triggering alpha prot disconnecting the AP. This caused altitude bust by 3000ft. Interestingly the genesis of Airbus FBW is in the fact that Bernard Ziegler it's master mind built it so because he was pissed off with French pilot's unions attitude that pilots never make mistakes and it's immoral to blame pilot if they are dead. He disliked this elitist attitude of the pilot community which at least in Europe came from a influential class. He said this aircraft why! Even my concierge can fly. He had even received death threats. You may read a very interesting 2014 article by William Langewiesche on AF 447 in Vanity fair.

17th Jul 2021, 11:59
Don't think that
AI is some godlike system that does not make a mistake. AI is a set of computer codes written by some computer geek who has probably never even flown a C152.The scope for code stuffups (bugs) is vast, and many code possibilities may never be fully checked for bugs. So you should EXPECT that your automation will one day go walkabout, right when you need it. To suggest that AI can solve safety issues in flight is downright naive. Accountants are naive in the ways of both flying and AI. Don't allow them to put pilotless aircraft in the skies...

17th Jul 2021, 12:57
I've called a few go rounds over the years when the approach was destabilised and it always became a single crew go round as, due to overload, the PF froze. I guess it's the task saturation that causes it, the blinkers go on and tunnel vision doesn't allow for a change of plan, it's been happening for years, level of experience has no bearing on the outcome, because I think the more experienced find it harder to come to terms with the rapidly deteriorating situation. PM should be prepared to take control if necessary.

17th Jul 2021, 14:06
How fortunate that you were on board, every single time, to save the day when the PF froze. Or perhaps you are just exaggerating?

17th Jul 2021, 14:13
I estimate that the best course of action would be disregarding the alert and proceeding with approach and landing. Of course, CdB would have needed to explicitly say so.

Now, let's see how many of you will fail to resist the temptation of answering this post without reading the BEA report first (available in English).

17th Jul 2021, 14:26
The tone of this discussion really frightens me. Pilots are supposed to remain cool, even in the face of imminent death, and salvage the situation without damage to people or the aircraft. I am glad that, due to advanced age, I probably have made my last flight.

17th Jul 2021, 15:26
Good evening to all,

Sorry if already online on this site, you will find below the url of the video of the French B.E.A about the incident :


Complete report (in French) :

Official French Report (https://www.bea.aero/fileadmin/user_upload/BEA2020-0065.pdf)

17th Jul 2021, 15:41
On a side note, even if that's sprinkling salt...

The Airbus FBW is already equipped with automatic WSH recovery, if you will. It's called TOGA detent of TLs in the FCOM. Assuming the AP is ON as the case was during the occurrence discussed.

A320 procedure for reactive Winshear Alert when sensed by the FACs (audio WINDSHEAR - WINDSHEAR - WINDSHEAR):1) Set THR LVR to TOGA detent (firewall) while announcing simultaneously "WSHR- TOGA".
2) Done.
3) (does not exist) No change of flap configuration or gear.


In case of a predictive warning from the forward-looking WXR feature (late in the approach with audio "GO AROUND, WINDSHEAR AHEAD”). Yes, this one is more tricky, so copy-paste the FCOM-ABN memory items verbatim:1) GO-AROUND...................................................... ....................................................PERFORM
2) AP (if engaged).................................................... .................................................... KEEP ON


This should not be hard.

Sarcasm aside, there's evidence now and then it is. Looking honestly at the SHELL model, the conclusion is bitter.

17th Jul 2021, 17:11
The Airbus FBW is already equipped with automatic WSH recovery, if you will. It's called TOGA detent of TLs in the FCOM. Assuming the AP is ON as the case was during the occurrence discussed.
The next mod will be the FACs will trigger TOGA/Alpha Floor and AP will come on. Idea is to offer relief to, not the pilot but human factor specialists.

17th Jul 2021, 18:00
Cabbages, I've been a TRE/Line Trainer since the late 1990s. You may have misunderstood my point...in every case, the PF was not planning nor expecting to to go around....

however thank you for your input, great username btw...is that what crew control call you?

Flying Clog
17th Jul 2021, 18:13
hec7or - unless you work for BA. Then the PF is always planning 'expecting' a go around, and the PM takes over at minima and lands the approach. Don't know anywhere else that does this however. Seems to work for them.

17th Jul 2021, 18:53
clog....delete planning, insert expecting and yes, I understand the principle of the monitored approach, but if the go round is unexpected and PF freezes, PM becomes the PF

17th Jul 2021, 18:56
Was flying a very stabilized linked three axis approach a few weeks ago to 300-1/2 or so. Just after FAF I had an alert from a very excited controller about “excessive descent rate”. I disconnected the autopilot and hand flew the rest of the approach (after inadvertently giving about a 2g yank in response to the radio call). Landed uneventfully and called the tower to ask WTF was up, as I was never more than a dot off the GS or much of anything off the assigned altitude. Manager said that they concurred that there were no deviations, and “sometimes the computers just do that”.
Not entirely sure that technology is our best friend sometimes...

17th Jul 2021, 20:23
Great response hec7or......wheeling out the, 'I've been a TRE/Line trainer since the late 1990s...' really made me chuckle. Thank you.

17th Jul 2021, 20:36

I'm not enjoying your sarcasm dude. Not knowing your level of aviation please allow me to state that on the B737 upon pressing TOGA the autopilot will disengage. Just when you need some help, the damn thing has a coffee break! The thrust will come up though to a nice sensible level.
A few of my friends have told me first hand of the F/Os going around and losing the plot mostly due to the pitch. They had to take over before the day was seriously ruined.
Mostly great guys and girls but a few get very over confident before even 1000 hours on type. They know the books better than me and their knowledge is fine, but they don’t know a jet has teeth and is waiting to bite you hard. Very hard and very quickly.
So yes, the ‘Old Man’ is there to save the day so we all go home safely.

17th Jul 2021, 21:07
Cabbages, the reference to training was to add context, a single pilot go round is nothing to chuckle about

17th Jul 2021, 21:28
Lessons to be learned / Issues to be understood:-

Specifically brief GA procedures which require lower altitude level-off than normally encountered. Also those procedures requiring a turn which could be coincident with alt acquire.

Review training methods for predictive WS GA, compare this with reactive windshear requiring a full escape manoeuvre. Could the training for the warnings mislead crews (considering them to be the same), overlooking that PWS is constrained by ATC procedure with Alt limits, whereas Reactive WS mandates climb until safety is assured.
Would either of the trained procedures conflict with airport procedures; PWS GA level off, Reactive WS ignore procedural restrictions - climb for safety.
How would ATC know the difference between GA due to predictive wind-shear and a reactive WS GA.
What reaction / clearance might the crew expect; ATC reaction, surprise for some, startle for others. Follow SOPs, except …

Consider cognitive dissidence between WS GA mental model requiring continued climb vs Alt alerting - level off during a predictive warning. Cognitive overload - cognitive incapacitation - unable to change focus of attention, reconsider the situation, attempting to resolve which procedure to use, when.

Review WS checklists involving the above.
Identify misleading - incorrect terminology for Alerts (amber) and Warning (red).
Not to place ‘notes’ before boxed memory items (dual use; checklists-for-real vs checklists in ground school training vice other documents).
Also any caveat that a red warning can be ignored - requiring further, delaying situation assessment - more mental workload.

Check if Red is always used for Predictive WS displays - red warning in PFD, but some other colour on ND / Radar.

Review Pprune mindset re ‘blame’, ‘incompetence’, etc; judgement cannot be made unless we were there, and even those who were, may be unable to provide reasoning for their actions (human condition).

17th Jul 2021, 21:49


I’m not in the game anymore but as a result I’m old enough to have pretty much seen the start of LOFTs being introduced…on maybe an annual basis ( and I don’t deny they are a good thing )through to the point where as you describe almost every failure/scenario seems to have to be placed in a LOFT context ….”right we are starting this section with a little flight from Manchester to London” and as a result valuable time is wasted on amongst other things on for example yet another bespoke in-flight landing distance calculation which you were doing every day on the line.

17th Jul 2021, 23:13
I average about one go around per year and whilst it's practiced regularly in the simulator I've learnt not to rely on correct actions from the F/O every time, often due to inexperience and startle effect.

When I go around it's with the expectation that I'll have to do the whole thing myself and any assistance from the right seat is a bonus.

18th Jul 2021, 00:49
One of the reasons my outfit started briefing go-arounds with every approach brief. We had a spat of badly handled go-arounds that needed a solution. Now we get to talk about it before every landing, including what triggers it, the call outs PM/PF actions, departure direction (missed app depiction or visual with tower?) altitude etc.

18th Jul 2021, 03:53
A good practice is to brief the actions, not just the chart. Especially in windy conditions. Ask your junior colleagues what they would do in the event of.... Same applies to a rapid decomp if you're in the loo or an engine failure in cruise. Then feedback the responses to the training department :}

18th Jul 2021, 06:02
Hi safetypee

This is all well intended, but you just lost your FO ...

18th Jul 2021, 07:26
One of the best design features on the (ancient technology now) 757 is when you engage GA on the AT it doesn’t go to max power but just enough to give you 2000FPM which is plenty when your level off is likely quite close, it also keeps the pitch change to a minimum

I found this really helped to keep go arounds much calmer and easier to manage

18th Jul 2021, 08:26
In almost 40 years in aviation and over 20,000 hrs of flight time I have had 2 significant failures.
A catastrophic engine failure and an airspeed unreliable.
The startle factor was huge.
I lived to tell the tale because of;

1. Experience , including lots of single Pilot night freight in a turboprop. (You cant buy that nowadays.)
2. Excellent training ( including some with your mob tdracer.)
3. A highly competent F/O in the right hand seat.

This thread and others leaves me a little despairing.
Do newbies take the profession of Pilot seriously?

Auto Windshear protection ?
Auto TCAS protection ?
Auto Emergency Descent protection ?
Flight Director into the flare ?
Really ?

Maybe I’ll start taking the train………

18th Jul 2021, 08:41
Yeah, because the Boeing product is a shining example of quality and engineering excellence.!
You mean like the B737 Max or 787 fuselage issue or even the 777X which is getting delayed. FAA doesn't see eye to eye with Boeing after they were taken for a ride with MAX.

18th Jul 2021, 09:01
Do newbies take the profession of Pilot seriously?

No they don't. I'm shocked to see how many pilots love the fact the job is becoming more and more automated. I'm actually sick of watching these guys never hand flying and using AP from 500 feet AGL down to 500 feet or less before touch down in CAVOK conditions when our outfit allows flying raw data. To be fair to them, some have been brainwashed by some so called instructors who push them to use automation all the time... If they could engaged the AP for take off until entering the gate they will happily do it. Of course not all of them but a lot of pilots now don't care about actually flying the plane. They just do it for the money. They barely know how to hand fly for most of them anyway. So sad... I'm flying the A320 now I love this aircraft very much but I would prefer to fly a 707 or something with less automatism to be honest. But these guys they would rather fly the A350 cause it will do the emergency descent and brake to vacate for themselves. Lol

18th Jul 2021, 09:12
A good gambit for go-arounds is for PF to re-brief it just before doing it :

"If I have to call 'go-around flap' I will set TOGA and pitch up to 15°. I will read out the FMA. You will set flap, check thrust and vertical speed, and call positive climb. I will call gear up, you will check speed-brake is in. Missed approach ALT is set: xxxx. OK?........Right....Go-Around".

Even simply telling PM what memory drill you are going to call, immediately before actually calling it, gives PM a head's-up :

"Ready for windshear memory drill?.........Windshear TOGA".

Nick 1
18th Jul 2021, 09:45
@Tukwillaflyboy ,
i remember when i start flying , the old guys in the DC-9 put a specific amount of attitude in the artificial horizon , and a nanosecond later the cross bar of the flight director converge at that specific point , to them the f/d was just a confirmation of their set-up , today if you remove it or ask to fly without it’s panic .

Roj approved
18th Jul 2021, 13:13

Isn’t this a standard function on the Boeing WB’s from the 757/767 onwards? The 787 had it.

Airbus now has it as an option - Soft GA or some such thing.

18th Jul 2021, 13:26

"Ready for windshear memory drill?.........Windshear TOGA"
Are you serious?

Flying Clog
18th Jul 2021, 15:26
And the 747. Common sense 2000 climb

Flying Clog
18th Jul 2021, 15:28
Absolutely. I pre brief all potential windsheer go arounds, or when ATC seems to be monkeying about with crossing or lining up traffic. As much for my benefit as the 350 hour numpty sat next to me in a jumbo.

Check Airman
18th Jul 2021, 15:37
hec7or may have benefitted from being the PM instead of the PF. If you think about it, the PM usually has more time to asses the big picture, and by the time he’s called for a GA, already is a few steps ahead, while the PF who’s struggling with the difficult approach is only keeping up.

Check Airman
18th Jul 2021, 15:42

Agree with your last statement. Training should minimise or eliminate adverse effects of being startled.

I’ll repost what I posted on the other thread:

Under stress, you will not rise to the occasion- instead, you will sink to your level of proficiency.

Good Business Sense
18th Jul 2021, 15:51
On all approaches, I mentally used to self brief ....... "this a go around to a possible landing" (takes ALL the stress and startle factor out of it) and at the FAF/OM I would mentally run through the drill for the GA. If there was any possibility of a GA I would share my self briefs with the copilot.

18th Jul 2021, 15:55
I've heard this before but being on edge all the time has negative effects too and it sucks the fun out of the job, no?

Flying Clog
18th Jul 2021, 16:15
Nonsense, you're average PM FO is not going through that thought process. Just how soon he can turn his phone on after landing to check his what's apps, all dependant on the Captain's mood.

Im my humble experience.

Flying Clog
18th Jul 2021, 16:17
Good Business Sense

Absolutely, that's the ticket.

18th Jul 2021, 16:21
Thanks Stilton for your bringing up the "soft go-around." Some years ago I was riding on Lufthansa from Frankfurt to Cairo. Weather CAVU. While on approach at about 1500 feet, suddenly the nose pitched up and TOGA came on abruptly. Scared the **** out of me and many of my fellow passengers. What happened? The runway was fouled by a slow-departing aircraft. Clearly a gentle application and gentle pulling up the nose was the appropriate thing to do. No point in upsetting the fare-paying passengers. Nufsaid.

18th Jul 2021, 16:42
I enjoy the arrogance of all the pilots here who never make mistakes and were born with 10,000 hours of hand flying skills. The "Children of the Magenta" line has been trotted out since 1997 when Cpt Vanderburgh first posited it. That was 24 years ago fellas. The 20 year old cadets back then are now the 44 year old line training captains. The 30 year old senior first officers/new captains are 54 year old management pilots. The 40 year old training captains became 64 year old heads of fleets/chiefs of some department or other and they had the power to direct and control training for 24 YEARS! You need more time to redirect training? How much more time? 50 years?

And to push the blame onto the new pilots of today/Children of the Magenta in 2021 is hypocrisy in it's truest form. You were Children of the Magenta and you created and trained and reinforced everything for decades. Please tell me how a 21 year old cadet is supposed to develop hand flying skills etc with a training department and FDM that specifically prohibits it? Who's fault is that? The 21 yold kid eager to learn? Or all these older 'experts' who are just magic?

Wakeup and see where the real issue is; we might just get a nice swansong before automation replaces us all 100%

18th Jul 2021, 16:44
For an English translation of the original French report on this event, go to the very first post of this thread, to the AvHerald link. On the third paragraph where it says "final report" it is a link to an English translation courtesy of the BEA.

There was a time in which I used to go around 8 times a week to this airport. From the Metars on AvHerald, it looks like the typical frontal weather moving from west to east. The TCUs pass over Paris and continue on their easterly movement, and start to "party" 10 or 15 miles east of Paris due to the excitation of passing over the town. This is the area where the approach is done to Orly, and often one has to endure some turbulence and ask to avoid the worst of it. Often it is clear skies to the west of the airport, but to the east, on the approach path, it looks ugly. For sure some turbulence was likely at the time, but I doubt that they had a Microburst on top of them, or ahead of them.

It seems that now the machine decides and orders a Go-around when its inbuilt parameters are reached, instead of just advising of possible Windsheer ahead. "GO AROUND, WINDSHEER AHEAD"

18th Jul 2021, 16:50
Airbus now has it as an option - Soft GA or some such thing.
Even with Airbus without the function it’s very simple. Just go back to climb detent after setting the thrust levers to TOGA. Makes life much easier. Well in that incident even with soft go around function it did not help much but I guess if they have used TOGA only it would have been much worst.

18th Jul 2021, 17:17
Thank you Vilas, an extremely illuminating article


Contact Approach
18th Jul 2021, 18:36
PriorPreparationPreventsPissPoorPerformance is what I was taught. Served me well so far.

19th Jul 2021, 00:31

Where I come from 30 years ago you wouldn’t get near a domestic airline without 3000 hours and lots of twin time.
Because the recruiters knew that the entry level jet was two-pilot.
Thats the point.

19th Jul 2021, 05:04
Roj approved

I’m sure it is, the 767 was the last aircraft I flew

My point is, this GA function was a big step forward from the aircraft I flew before, the MD80 which went to full power with GA selection and it took a lot of ‘restraining’ !

Roj approved
19th Jul 2021, 06:36
G’day pineteam,

Ahh, the old “TOGA TAP”, it works well when executed correctly.

One of the local operators in AUS have a checkered history with it. https://www.pprune.org/australia-new-zealand-pacific/290637-jetstar-a320-go-around-melbourne-4.html

From watching the BEA video, and reading this from Airbus, https://safetyfirst.airbus.com/introduction-to-the-soft-go-around-function/

the “SOFT GA” is a variation on that, Levers to TOGA -> FLEX/MCT to get the Soft Go Around.

Unfortunately the most important part was forgotten, FLY the aircraft, they did everything but control the pitch.

Roughly 1 minute without any side stick inputs to arrest the rate of climb, but the Gear came up, Flaps were retracted, Thrust levers moved and the FCU was fiddled with.

The added distraction of the Traffic probably contributed to the second mishandling event, but eventually, the Captain got it under control.

It is a good reminder to establish who is “In Control” and what the aircraft is doing, IE: KNOW THE FMA.

But it won't help if your dealing with GPWS terrain alert where you need maximum performance from the aircraft. It's better if you leave the choice of thrust with the pilot.

A second push on the TOGA switch gives you full noise, SOFT -> FULL, so it’s the opposite to the Airbus FULL-> SOFT.

From memory, if W/S, GPWS or a GA, just push the TOGA button AND push the Thrust Levers to Full Thrust. Maybe the Boeing guys can confirm?

19th Jul 2021, 07:47
Jet Star incident was due to company's incorrectly revised procedure about missed approach. Perhaps somebody forgetting to raise gear in a GA in the past, Jetstar relegated FMA check after gear was selected up. In this Melbourne go around the pilot inadvertently pushed thrust levers short of TOGA or full forward position. The aircraft remained in approach phase. The PF didn't check FMA as per the revised procedure but waited for positive climb call from PM to order gear up. The PM waited for the positive climb which didn't happen because FDs were in approach phase and taking them down. Vis was below CAT1 minimum, at 35ft. PF ignored the FDs and pulled up the aircraft. After this incident Jetstar reverted back to the correct Airbus procedure of first TOGA, then confirm GA phase by checking the FMA only then everything else. There were two other airlines involved in similar incidents. Actually even with full TOGA power there's no need to play with thrust levers preemptively. What needs to be remembered is the moment SRS changes to OP CLB it signals acceleration and eyes must shift to the speed tape and order immediate flap retraction. That creates sufficient space for other activities like thrust reduction and next flap reduction.

19th Jul 2021, 08:11

In the event of a GPWS terrain warning, the procedure is to disengage the autopilot and auto throttle and "aggressively apply maximum thrust" while pitching up. The TOGA switches are irrelevant in that situation.

19th Jul 2021, 08:22
IIRC, the 737, as far back as the classic, had the "one tap/2000', 2 taps TOGA " selection. Certainly on the NG.

19th Jul 2021, 09:00

Yes I am deadly serious. This was taught to me by a very experienced senior Captain. Flying is a team effort and you both need to be on the same page. If one pilot can detect a problem approaching - for example you as PF are touching the end stops on the side-stick while flying a turbulent approach, then it makes very good sense to tell PM you might need to go-around, and get them primed so they are ready. Why wouldn't you ? Talk to me Goose.

If the other pilot is a few hundred hour newbie, it makes even more sense, otherwise you might be doing an OPI (one pilot inoperative), go-around, and potentially forgetting the gear and the speed brake in the process.

19th Jul 2021, 12:30
All engines operating high energy go arounds are statistically speaking one of the most screwed-up manoeuvres within our Industry. There are tons of very well written articles and safety briefings reporting events and incidents over the past years involving mismanaged go arounds and the bottom line is to brief and rehearse the actions during the approach briefing highlighting the important threats. And this is another thing: threats briefings. Pilots tend to look for threats all over the place because it must be included in the briefing, it is in the SOPs so we must talk about some threats. Excellent, that is very true, but we must talk about real threats, stuff that is beneficial to us. During line checks or sim checks I occasionally see pilots talking about threats such as "Atc, terrain, weather, complex taxi routing... anything else?" How effective is this? Zero, but hey you've considered many important aspects so you can put the checkmark on the threats part of the approach briefing. Threats must be very specific and as pilots we must have a few very clear key points for the approach (same as for departure btw) that stick to our brain to prevent getting caught in the action.

Check Airman
19th Jul 2021, 13:12

I think it’s quite a sensible thing to do. My last company would have us each walk through our RTO actions in sequence at the start of each pairing (or maybe it was each day). Whatever it was, I thought it was a great idea, even if it did make the briefing a bit longer.

19th Jul 2021, 13:32
Coming back to A350 pilot's startle case, today exactly 32 years ago United flight 232 with catastrophic failure of tail mounted engine, the flight controls became disfunctional. It was a fit case for Capt Haynes and crew to get a heart attack but they kept their wits about and worked out a procedure to use thrust to pitch up and down and asymmetric thrust for bank. They created history by controlled crash landing and saving 184 lives out of 296. And here a false windshear warning knocked the crew out of their wit and for some time nobody knew what was happening. Are some more humans than the others? I remember hypnosis shows in which the hypnotist says ,"Sleep" and the person flops into unconsciousness. If this is going to happen in the air then it's a terrible human factor. In that case pilots would need to be checked for hypersensitivity to stress, startle or whatever you may call it.

19th Jul 2021, 14:34

You conveniently modified my post in your reply to "pre briefing a memory item".
In your first post you stated "Ready for windshear memory drill?.........Windshear TOGA". My question was if you had a windshear warning were you seriously going to say "Ready for windshear memory drill?.........Windshear TOGA". Rather than act calling "Windshear TOGA", I was not questioning the prebriefing of any actions that might be required on an approach, all good airmanship. But the way you wrote your comment was you would waffle before acting losing possible valuable seconds and altitude in a real windshear event.

Nick 1
19th Jul 2021, 14:51
I’m trying to figure out when and why the speed brake where pulled out during a go around / ws escape maneuver ....

19th Jul 2021, 16:54
It would help if posters referred to the report (https://www.bea.aero/fileadmin/user_upload/BEA2020-0065.en.pdf) so that questions can be posed based on a common document.

PF surprised - this was in relation to ‘the day’s meteorological conditions, the predictive windshear warning’ (page 9).

The PM initiated the GA; the checklist had a note (before the memory items !), that after risk assessment a predictive (Red) warning could be disregarded !

The ‘captain-PM who called out “Go-Around”, the copilot-PF had replied, “Go-Around flaps” and the captain retracted one notch of flaps’; the soft GA mode was used, which with config change suggested a normal GA - missed approach procedure (page 10).

The narrative suggests that the crew were ‘behind the aircraft’ after GA selection(PF thought the AP was engaged), and due to the lower than standard altitude limit, coincident with a procedural turn.

The Capt took control after the Alt Bust, aiming to regain the cleared altitude. There was conflicting traffic above, ATC requested a turn. Further ATC calls added urgency about the traffic, and then cleared the aircraft for further climb; potential for high task workload, with distracting aircraft alerts, and ATC calls.

The report covers the scenario from each crew members viewpoint.

Pre briefing specific drills (based on hindsight), #97 could bias crews to select incorrect procedures - this event only required a missed approach or even none at all.

19th Jul 2021, 17:11
Interspersed with the usual playing of the man rather than the ball, there are some interesting views being expressed here. My own view is that this is a training issue and I agree that the sim should be used more for training than testing.

However, I don't think you can point the finger quite so directly at the regulator here: ...the regulator that want the pilot be trained at minimum level (post #29). We have been in a race to the bottom for some years and this is down to the operators who demand the cheapest possible TR or differences training for their pilots. The manufacturers respond to pressure from the customers and design a training system that will just meet the standard and must then convince the certifying regulator that it does, and adjusts it if not. The regulator then 'accepts' (rather than approves) the manufacturer's evidence that the training is up to the mark.

This is all about commercial pressure and the bottom line for the shareholder. Until the operators all accept that training needs to be taken seriously (as some do already) we will end up with a system where crews are 'just good enough'. Until they are not...

19th Jul 2021, 17:26
Absolutely right. Training and practise needs to be improved :ok:

@vilas, yes I don't know when trainers stopped checking that pilots could handle emergencies without running back to their Mums in tears. Years ago if you didn't make the grade, you didn't become a pilot. This seems to have changed ?

Hi iceman50, apologies if I misquoted you. Pprune software keeps dropping my quote boxes, so I keep them as short as possible. Anyway; it only takes about 2 seconds to say "ready for wind-shear drill?", or even just ask "Ready?", and by doing so you will remove any startle.

Hi Nick 1, if you are referring to my post, I am not saying it was, sorry. My point was that things could be forgotten.

19th Jul 2021, 21:54

"These were highly trained people,..."

Highly trained but not in actually flying an airplane.

20th Jul 2021, 00:14
Mr Optimistic

Aircraft configuration remains unchanged during a windshear escape procedure until you're clear of it.

20th Jul 2021, 00:32
What exactly does this mean?

The copilot, confronted with the surprise effect in connection with the unexpected triggering of the predictive windshear warning, the change in the rate of work and the increased workload was then “absent” for a few minutes. This cognitive incapacitation was not initially identified by the captain or the relief pilot.

Aside from that, the predictive windshear alert on the Bus is a bit annoying, and with SOP, it requires a GA...

20th Jul 2021, 04:02
I take it to mean the copilot froze. Deer in the headlights. Queeg in the typhoon. Mental circuit breakers tripped.

Ollie Onion
20th Jul 2021, 04:13
Air France have had a number of close calls due to aircraft mishandling….. makes you wonder if their is a systemic issue there.

20th Jul 2021, 04:45
They do but I don’t believe this was an AF flight

20th Jul 2021, 05:37

Predictive Windshear is not a memory item anymore, just a pilot technique and by FCTM you can disregard the alert as long as there are no other signs of possible windshear conditions and the reactive windshear system is operational.

Obviously common sense will be to be go around minded if there are any signs of hazards but there is no need to rush things.

20th Jul 2021, 05:40

True, but was this not windshear ahead which is not the same?

20th Jul 2021, 07:00
From the report it was indeed a predictive w/s alert hence the go-around decision from the PIC. Lots of human factor in this event I believe, especially in the final stages of a LH flight when You really need to push yourself to stand up to the situation as the traps of tiredness and complacency are opening their wide arms in front of You.

20th Jul 2021, 07:17
Add a couple more exams to the 14 EASA ATPL Exam List - that will fix things.:hmm:

20th Jul 2021, 09:32
Re: “I take it to mean the copilot froze.”
The word surprise can be interpreted in several ways; extreme fear <or> deviation from normal expectation based on experience. Also, different after translation;
Original - Il ajoute avoir été surpris, au vu des conditions météorologiques du jour, par l’alarme predictive windshear, can be translated as “He adds that he was surprised, given the weather conditions of the day, by the predictive windshear alarm”.
The differing tense (was surprised) from the official English report (had been surprised) enables different interpretations of how the situation is considered in hindsight - our expectations, our surprise.

The report indicated that the PF understood the Capts GA instruction, and that the initial normal GA actions were correctly executed, which suggests that any ‘impairment’ occurred after these actions.
The first deviation from normalcy appears to be related to the expectation that the AP was engaged - but it wasn't; soft TOGA thrust triggers mode change, the route is in FMS/ND, Alt set (all re-briefed by technology at the time of action) - except the aircraft did not respond as expected.
This conflict may have held the PF’s focus of attention, ‘highjacking’ cognitive resource - why isn't the aircraft flying as expected - as it would in the simulator, as the SOP, etc, …
Add the need to fly the route, alt acquire, … mind overload with situational reassessment, seeking understanding, insufficient capacity for control, … to remember events - mind elsewhere.

Re: “Predictive Windshear is not a memory item anymore,”
Interesting, which together with the FCOM note - reassess PWS, and info about spurious triggers, indicates the reduced value of the system.
Any system which claims to enhance awareness should be of higher integrity that the basic awareness - pre PWS the crew could interpret the weather radar as a situation which might / might not involve windshear, but avoiding uncertainty, as windshear training requires, with a GA.
In modern times, a new ‘ambiguous‘ radar sensor - is the display valid PWS or is the display false, and I can ignore it - true or false. What if the warning is true, a hazard, don't ignore, confusion, etc, …
Beware technology which ‘enhances awareness’, but actually ‘highjacks’ the mind, increasing mental workload.

20th Jul 2021, 09:57

Interesting analysis.
Guess you are a trainer?
I have been in this game for a while and the F/Os who are easiest to fly with and who are most reliable are those who have done something else.
Ex military or single pilot night freight , doesn’t matter. What they have in common is extra RAM when everything goes pear-shaped.
You cant buy experience and you cant train it in the simulator.

I don’t like Cadetship schemes.

Plus, as an aside , I don’t understand how “ cognitive capture “ or “hijacking the mind” can be the result of the extraordinary improvement in the technology in the cockpit over the last 40 years.
Its brilliant. But its a tool. Not and end in itself.

The problem is the operators.

20th Jul 2021, 10:28
This quote jumps out of the Vanity Fair article. “A senior executive at Airbus mentioned to me that in Britain and the United States the elites do not become airline pilots, whereas in France, as in less developed countries, they still do”
I’m not sure I’d agree that the job and (lack of) status of being an airline pilot nowadays attracts the “elite” , (however defined) to the job. I would also extend that to senior management and Directors too, sadly. The airline industry doesn’t attract the innovators or deep thinkers . I guess there are easier and more bucks to be had elsewhere.

20th Jul 2021, 10:56
Re: I don’t understand how “ cognitive capture “ or “hijacking the mind” can be the result of the extraordinary improvement in the technology in the cockpit over the last 40 years.
Not all technology; effects depends on how tech has been implemented and used. Consider situations as a combined system of man and machine, not one against the other in isolation.

e.g. https://www.atsb.gov.au/publications/investigation_reports/2016/aair/ao-2016-064/
An enhanced awareness display on the PFD -
“The pilot flying reported that the synthetic vision image created the impression …”
“Incorrect instrument indications that are not associated with a failure mode present pilots with a complex and challenging situation.”
“The synthetic vision system was not to be used for primary input or navigation, with the following warning in the Pilot’s Guide (used by the operator)”
“Pilot Advisory Letter included a description of the event. The letter also advised pilots that the use of synthetic vision is for situational awareness and should not be utilised for the indication of attitude or altitude in lieu of the primary flight display indications for pitch, roll, yaw, or altitude.“

… so ‘synthetic awareness’ is independent of aircraft attitude and altitude … design issue, regulation, operator, but not the pilot if able to …
“The check pilot immediately looked outside and was able to discern a visible horizon due to the moonlight.”

Relating to this incident …
the PF had the impression that the AP was engaged;
limitations for the use of PWS for ‘situation enhancement’
there were no aircraft system failure warnings,
reestablishing awareness must include man-machine-situation, this takes time and mental effort for the crew, but analysis in hindsight is not so constrained.

Joe le Taxi
20th Jul 2021, 11:16
I'm with you tukwilla, and in an environment where 80% of FOs come from high school through cadet schemes which indoctrinate adherence to encyclopedic SOPs before all else, if anything slightly unusual or surprising happens, you can see their brains desperately trying to access their recollection of the relevant SOP, rather than just flying the aeroplane, pitch and power then add the layers as capacity comes back in.

20th Jul 2021, 12:48
Never truer words said.

20th Jul 2021, 13:23

Dull, boring and pointless! Continual repetition simply breeds complacency and pattern matching. After 5 x Go-Arounds then 5 x Eng Out G/A the brain is already starting to slumber and the prospect of going into the training environment to do mind numbing repetition is miserable.

20th Jul 2021, 13:29
Perhaps we should be teaching cognitive and analytical skills rather than relying on muscle memory and SOPS’s? At the risk of being cynical,the airline training business is a sausage machine, and teaching to a budget has worked well for the airlines and the bottom line so far. I don’t doubt that the occasional hull loss is already priced into the share price.

20th Jul 2021, 15:55

Sarcasm, right?

The elephant in the room is that after each of those G/As the trainer must use a stick and beat crew hands bloody to get it absolutely perfectly right every single time, IN ORDER to enforce a proper drill-learning that can be later relied upon. Shooting 10x "somehow we managed well" does not build what is needed decades down the road. Is such a solution available these days? Definitely not in the western civilian world, and then it becomes simple. Train with foam swords, get gummi bears.

Guided cognitive instruction could achieve equivalent results but the resources are not allocated even in the best industry-practice syllabi. Having said that, a widebody FO freezing on a G/A he himself executed is hard evidence of training system failure.

20th Jul 2021, 16:02

How many circuits, landings and take-offs did we do for our initial flight training in a C172 - just one of each?

How many times do musicians practise a musical piece before performing it - just the once?

How many times do athletes, tennis players, footballers, sports people practise their skills before a competition - just the once?

what next
20th Jul 2021, 19:36
Yes. But all the rehearsals are done in vain if the artist suffers an attack of stage fright. And this is what happened here. That was a crew of very experienced pilots, who without any doubt knew very well how to properly fly a go-around. Practised it hundreds of times both in the simulator and in real life. But for some reason the pilot flying "froze" at the cotrols and the pilot monitoring didn't notice that condition right away. Would a more thorough briefing have prevented this "freezing"? How thorough would that briefing need to be? There is so much that can go wrong, briefing it all would take longer than the flight itself...

20th Jul 2021, 22:18
The reports does not explain how well they knew to fly a go-around. On the contrary, it does show they were not proficient to execute one in complex circumstances. Neither of the two situations you describe should have been allowed to happen, that's why standards exist. Passing the grade in the SIM but failing to perform when the day comes reeks of a dysfunctional training system, where the objective is not well understood.

Responsible reaction needs to take form of a preventive measure that - if sent back in time and applied to the incident crew involved - would had prevent the situation. In thorough agreement with your implied "but you cannot change a man or ultimately predict his reactions once he snaps", it's either the hardware, training or procedures that need focus.

+ Aircraft is capable of executing it on it's own, just keep the AP on.
+ The SOP for G/A works well and cannot be made any more simple. TOGA+flaps. Read FMA and adjust the targets, then gear up and call ATC.
+ If the situation stinks of going missed, perhaps a mini review is prudent. I started doing exactly that after the last one.
+ Training change is possible in two ways, more exercises or stricter evaluation.

Which one is it?

My money is on what sonicbum suggested. But most definitely they have not practised it hundred times in simulators or real life. "Done quite a number in the SIM, but never a real one on the type." - sounds more like it.


21st Jul 2021, 05:55
Joe le Taxi

Absolutely agree!
Those new pilots have been deprived of adequate training. The new syllabi for these new gen pilots, cost reduced beyond reason, address almost exclusively the cerebrum. SOP, procedures by memory items, QRH and so forth. The cerebrum can easily freeze in startle situations (qed by many recent incidents) and is not best suited to find the appropriate intellectual procedure in due time. The genuine basic formation though implies the cerebellum as well. This part is much less prone to freezing, but can only perform some basic functions without much intellectual thought. It is well developed in birds and there might be a reason. In startle situations they instinctively fly up and when safe their cerebrum takes it from there --> Pitch and power, when safe add appropriate procedures.
This can only be achieved by in field basic training. The modern CBT and SIM training will never achieve it adequately. If the argument is cost or environmental impact, then think: Basic training can be nicely done with new electrical training aircraft. They are affordable, underpowered, fly close to the ground and have little range. Exactly what sharpens the basic flying instincts of newbees and might be needed in startle situations.
There is no replacement for such skills. All the other necessary skills in modern aircraft and today's environment can then be acquired virtually.

21st Jul 2021, 09:54
@what next,

Yes, a long, tedious briefing before push-back or TOD, detailing actions for every eventuality is counter-productive, I agree - the recipient's eyes will glaze over and they will switch off.

But if it appears that a memory drill might be necessary in the very near future, no harm in voicing it and even running through the actions before doing it if there is time. And this will absolutely prevent startle and stage fright........and cock-ups !

If I am going from end stop to end stop on the side-stick during a turbulent approach, but PM cannot see this and I am keeping the aircraft's attitude fairly stable, I will nevertheless say, "hmmm, we might have to go-around in a minute". Then at least PM is on the same page with me.

21st Jul 2021, 10:55
Predictive windshear is not a memory item on the A350, go around with TOGA is recommended in the FCTM.

21st Jul 2021, 13:08
Re: “The report does not explain … …, it does show they were not proficient to execute one in complex circumstances.” #123
This covers many aspects of this incident;

The difficulty in explaining complex situations; - often it is impossible to explain human behaviour, there will not be a single view which satisfies everyone.

There was no ‘showing’ - reasoned argument about proficiency; only that actions (with hindsight), were not as expected for the situation.

It is very difficult to change the human condition, easier to change the situational circumstance, which is what the report concluded.

There will always be errors; their relevance depends on the consequences. Forgetting - unaware that the AP was disengaged is labeled ‘error’; a human limitation, which in isolation was not critical. However, the consequence of adjusting to the ‘error’ resulted in ‘an undesired state’ - Level Bust - the hazard.

The report recommends reviewing the ‘complex circumstances’ of the missed approach requirements - GA altitude and routing; not proficiency or training.
Tacitly the report recognises that there are limits to human performance, which in a very safe industry might defy intervention focused on the human, e.g. training; alternatively changing the situations to be managed could help avoid a similar incident.

back to Boeing
21st Jul 2021, 16:57

Having never flown an airbus so no idea how the manuals are structured.

its a manoeuvre that needs to be flown from memory. It’s technically not a memory item on a Boeing either. But I wouldn’t open the QRH to brief myself on the manoeuvre if I got a wind shear warning.

21st Jul 2021, 20:51
I always thought, that the whole idea of an alarm, was to make you instantly aware of an issue / problem & to jog you into taking immediate remedial action.

25th Jul 2021, 00:43
FDR available but CVR not, and the BEA report does not specify why - perhaps the common reason that the aircraft was not held out of service and it was overwritten. That’s unfortunate, given the circumstances, no? The CVR would not have filled in all the gaps left by the FDR but it would have helped corroborate the interviews - especially if there was a significant lapse of time before these occurred also.