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punkalouver
10th May 2022, 14:39
"Crew failed to monitor speed loss before 757's aggressive manoeuvres
By David Kaminski-Morrow10 May 2022

US investigators have found that aggressive control inputs to increase poorly-monitored airspeed resulted in injuries to three flight attendants on an American Airlines Boeing 757-200 descending to New York JFK.

The incident occurred as the aircraft was arriving from Edinburgh on 6 September 2018.

According to the newly-released final conclusions from the US National Transportation Safety Board, the autopilot’s ‘altitude hold’ mode engaged as the 757 neared its pre-selected altitude of 12,000ft having descended from 24,000ft.

Some 16s later the aircraft’s altimeter setting changed – from the standard cruise setting of 1,013mb to 1,020mb – and this caused the altimeter immediately to display a higher altitude of 12,100ft.

The captain, who was flying, opted to re-acquire the desired altitude of 12,000ft by selecting ‘flight level change’ mode and the autothrottle responded to enable the aircraft to descend.

But the crew also chose to decelerate slightly, from around 255kt, by selecting an airspeed of 250kt – which caused retardation of both thrust levers. When the thrust levers reached their aft stop, the autothrottle entered ‘throttle hold’ mode.

The cockpit crew, which included the two pilots and an international relief officer on the jumpseat, undertook an approach briefing during which air traffic control cleared the jet to descend to 7,000ft.

Investigators found, however, that the aircraft – still in ‘flight level change’ mode – was trying to maintain its selected altitude of 12,000ft having reduced thrust. The airspeed started bleeding away and the 757 pitched nose-up to try to hold altitude.

The inquiry says the relief officer remarked three times in succession about the declining airspeed, over the space of 5s, and recorded data showed it had fallen to 186kt.

Thrust levers were suddenly advanced, the autothrottle exited ‘thrust hold’ mode, and the engines powered up.

“Push, push it over. Get the autopilot off, push it over,” the relief officer stated loudly, concerned that the airspeed was “dangerously low”.



Both the autopilot and autothrottle were disengaged and, with the aircraft 10° nose-up, the control column was moved quickly forward to command nose-down attitude.

“These aggressive manoeuvres caused the flight attendants in the aft galley to be thrown against the ceiling,” says the NTSB. One of them suffered a fractured arm, and two others were injured.

The pitch varied between 10° nose-up and 3° nose-down, with fluctuations between positive and negative g-forces over an 11s interval before the airspeed, pitch and control column positions stabilised and the jet started descending to 7,000ft.

It subsequently landed without further incident. None of the 104 passengers or the other six crew members was injured.

The captain had accumulated over 13,600h on type while the first officer had 565h.

Investigators state that the crew’s failure to monitor the airspeed adequately led to aggressive control inputs in an effort to accelerate, resulting in the injuries to the cabin crew."

From Flight International.

Gotta admit, I like to momentarily check the flight instruments while giving the briefing, just to ensure that there is still a sort of monitoring function.

DaveReidUK
10th May 2022, 15:33
Report DCA18LA285 (https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98259/pdf)

Uplinker
10th May 2022, 15:47
Did we enter some sort of parallel universe a few years ago - one in which pilots don't know how to fly, or scan their instruments? :confused:

blue up
10th May 2022, 16:36
Is it usual to brief for NY when half way down the descent? We used to brief during the cruise and cover the options so we could add a mini-brief if the situation changed. Bugger all else to do when crossing the Atlantic

MLHeliwrench
10th May 2022, 19:17
Did we enter some sort of parallel universe a few years ago - one in which pilots don't know how to fly, or scan their instruments? :confused:

Even with a qualified relief pilot yelling in your ear? I suspect there were numerous nervous glances and interesting body language at each other once the ship was righted.

ASRAAMTOO
10th May 2022, 20:15
Wow, definitely a parallel universe when it takes almost 4 years to produce a report from an incident where the aircraft and all crew and pax survived!

733driver
10th May 2022, 20:38
Did we enter some sort of parallel universe a few years ago - one in which pilots don't know how to fly, or scan their instruments? :confused:

It's just too easy to be a keyboard warrior. Thousands and thousands of safe flights everyday so I don't think it's appropriate to deduce from isolated incidents that pilots these days don't know how to scan and fly. Lessons to be learned for sure but no need to dramatize and generalize, I think.

Dropp the Pilot
10th May 2022, 21:08
Thousands and thousands of hours sitting behind pilots in the simulator from which I can tell you........ pilots these days don't know how to scan and fly. There is a need to dramatize and generalize. Think of the manifold and lethal ways in which gross ineptitude has been demonstrated at Air France for a start and then move eastward from there to where the true horrors begin.

Uplinker
10th May 2022, 22:23
It's just too easy to be a keyboard warrior. Thousands and thousands of safe flights everyday so I don't think it's appropriate to deduce from isolated incidents that pilots these days don't know how to scan and fly. Lessons to be learned for sure but no need to dramatize and generalize, I think.

Well, let's see. Off the top of my head there has been, in recent years :

A crew who also did not watch their airspeed and crashed short of the runway at SFO.
A crew who forgot to select go-around thrust when attempting to go around.
A crew who almost forgot to take off.
A crew who did take off but without any airspeed readout because the pitot covers were left on.
A crew who took off with both engine cowl flaps undone.
A crew who attempted an approach while so hot and high they forgot to lower the gear, scraped and damaged both engines along the runway, somehow got airborne again, only to crash.
A crew who after landing in a crosswind used the yoke like a car steering wheel to try to stay on the centre line, instead of the rudder, and went off the side of the runway.
A crew who landed so deep and in a tailwind, they went off the end of the runway.
A pilot who held full back-stick at cruising altitude, fatally stalling the aircraft.
A pilot who broke off the fin by incorrect use of the rudder during turbulence

Were these not all very basic piloting errors ? Seems like a parallel universe to me !

PS, Am a 'joe average' qualified long haul and short haul pilot, not an armchair amateur :ok:

733driver
10th May 2022, 22:46
Well, let's see. Off the top of my head there has been, in recent years :

A crew who also did not watch their airspeed and crashed short of the runway at SFO.
A crew who forgot to select go-around thrust when attempting to go around.
A crew who almost forgot to take off.
A crew who did take off but without any airspeed readout because the pitot covers were left on.
A crew who took off with both engine cowl flaps undone.
A crew who attempted an approach while so hot and high they forgot to lower the gear, scraped and damaged both engines along the runway, somehow got airborne again, only to crash.
A crew who after landing in a crosswind used the yoke like a car steering wheel to try to stay on the centre line, instead of the rudder, and went off the side of the runway.
A crew who landed so deep and in a tailwind, they went off the end of the runway.
A pilot who held full back-stick at cruising altitude, fatally stalling the aircraft.
A pilot who broke off the fin by incorrect use of the rudder during turbulence

Were these not all very basic piloting errors ? Seems like a parallel universe to me !

PS, Am a 'joe average' qualified long haul and short haul pilot, not an armchair amateur :ok:

Didn't mean to call you an amateur. But we are all Monday morning quarterbacks here.

Your list above is valid and relevant but when put into context of more than 100.000 commercial flights a day around the world, that's 36.5 million flights in just one year, I think we must be doing something right. The AA brand alone has more than 6000 daily departures.

sherburn2LA
11th May 2022, 06:50
I am wondering about the parallel universe where 186 kts is a dangerously low airspeed requiring aggressive intervention

BuzzBox
11th May 2022, 07:28
I am wondering about the parallel universe where the autopilot remains in FLCH mode when the aircraft levels off at the selected altitude. Is there something different about the B757 to other Boeing types (eg B744, B777)?

rudestuff
11th May 2022, 07:47
I am wondering about the parallel universe where the autopilot remains in FLCH mode when the aircraft levels off at the selected altitude. Is there something different about the B757 to other Boeing types (eg B744, B777)?
Nope. Approaching the MCP altitude it should go to ALT CAP then SPD/ALT HOLD. The Auto throttle should wake up.

Less Hair
11th May 2022, 07:50
Mode confusion in some iron aircraft? Think about if this had happened in some bus?

FlightDetent
11th May 2022, 08:36
Mode confusion in some iron aircraft? Think about if this had happened in some bus?It would had been the P2F south-east Asia cadet's fault

SpamCanDriver
11th May 2022, 09:47
Well, let's see. Off the top of my head there has been, in recent years :

A crew who also did not watch their airspeed and crashed short of the runway at SFO.
A crew who forgot to select go-around thrust when attempting to go around.
A crew who almost forgot to take off.
A crew who did take off but without any airspeed readout because the pitot covers were left on.
A crew who took off with both engine cowl flaps undone.
A crew who attempted an approach while so hot and high they forgot to lower the gear, scraped and damaged both engines along the runway, somehow got airborne again, only to crash.
A crew who after landing in a crosswind used the yoke like a car steering wheel to try to stay on the centre line, instead of the rudder, and went off the side of the runway.
A crew who landed so deep and in a tailwind, they went off the end of the runway.
A pilot who held full back-stick at cruising altitude, fatally stalling the aircraft.
A pilot who broke off the fin by incorrect use of the rudder during turbulence

Were these not all very basic piloting errors ? Seems like a parallel universe to me !

PS, Am a 'joe average' qualified long haul and short haul pilot, not an armchair amateur :ok:

Good examples

But are we going to pretend similar accidents didn't happen in the past?

Uplinker
11th May 2022, 10:01
Didn't mean to call you an amateur. But we are all Monday morning quarterbacks here.

Your list above is valid and relevant but when put into context of more than 100.000 commercial flights a day around the world, that's 36.5 million flights in just one year, I think we must be doing something right. The AA brand alone has more than 6000 daily departures.

None taken. I agree that on the whole flying is very safe, but I am getting increasingly alarmed that some very very basic mistakes are being made. These are not caused by complicated equipment failures - or any equipment failures - these are caused by pilots not being pilots; not looking at their instruments, not doing a proper walk around, not controlling the automatics etc.

These basic mistakes should not be happening - there are at least two pilots on these flights and the SOPs have a large amount of cross checking and confirmation between the pilots to catch all the small errors we all make. And by small errors, I do not mean failing to scan the instruments; that is fundamental. And if the automatics are not doing what you need, the pilots should catch this and take appropriate action. Jet pilot 101.
The pilots in this latest incident not only failed to monitor the automatics or watch their speed, but it seems they panicked in their recovery, instead of smoothly reacting.

Granted, we might not all be as successful as Captain Sullenberger and F/O Stiles were when faced with a double engine failure at low level - fantastic piloting - but we should at the very least be capable of flying normal manoeuvres and scanning correctly.

When I fly and even when I brief, I regularly glance at my PFD - just as you do when driving your car, you (should) regularly glance in all three mirrors as well as looking forwards so you know what traffic is around you, as well as monitoring your car speedometer. Same with aircraft instrument scans.

I seriously think that training, testing and recurrent Sims need a big shake up. Really the XAAs should conduct them so there is no favoritism or knowledge of the pilots.

edit to add answer to SpamCanDriver, No, but in aviation we are supposed to learn from everyone's previous mistakes and not repeat them. We seem to be going backwards safety-wise at the moment.
.

Fursty Ferret
11th May 2022, 13:25
Think about if this had happened in some bus?

Well, absolutely nothing exciting would have happened because the Airbus doesn't have the moronic HOLD mode fitted to the Boeing auto-thrust system. It would simply have changed from THR IDLE to SPEED.

HOLD is a hangover from the previous century when it was necessary to physically remove power to the autothrottle servos to prevent obscure problems instead of fixing those issues in the first place.

M.Mouse
11th May 2022, 15:26
I disagree that HOLD mode is moronic. What is moronic is the mis-handling or lack of awareness and understanding of the aeroplane systems operation.

On the B777 and B787 the HOLD mode software has now changed in that speed protection, i.e. Autothrottle Automatic Activation, now functions when in that mode. I presume the change applies to other models as well.

SpamCanDriver
11th May 2022, 18:44
edit to add answer to SpamCanDriver, No, but in aviation we are supposed to learn from everyone's previous mistakes and not repeat them. We seem to be going backwards safety-wise at the moment.
.

Absolutely agree we should

I was just referring to the theme that pilots wouldn't of made these basic flying errors in the past, when it was a more manual job.
They did make the same errors

hans brinker
12th May 2022, 15:54
Interesting that the pilot with 1009 hours TT was the telling the pilot with13.000 hours in type what to do.

Chronic Snoozer
13th May 2022, 01:30
Sounds like your beloved startle factor at play, Uplinker. :}

BoeingDriver99
13th May 2022, 01:47
I think that it took four years to produce this report as bordering on negligence. All FDR/CVR, pilots survived intact and an investigation with something to learn from it couldn't be produced in a few weeks/months?

And yes we are in a parallel universe where pilots cannot pilot anymore.

Bksmithca
13th May 2022, 03:35
Interesting that the pilot with 1009 hours TT was the telling the pilot with13.000 hours in type what to do.
As a flight engineer I needed to be type rated for the aircraft I was working, same with the pilots but why would the flight instructor not need to be type rated?

WideScreen
13th May 2022, 06:04
I think that it took four years to produce this report as bordering on negligence. All FDR/CVR, pilots survived intact and an investigation with something to learn from it couldn't be produced in a few weeks/months?
Looks to me, it was clear WHAT happened, though pretty unclear WHY this happened. As raised, that a 13k hours highly experienced pilot started to garble up and needed to be corrected by a young one. And, I still don't see a clear answer to that.
And yes we are in a parallel universe where pilots cannot pilot anymore.
Yep. This is not the first time, and it gives me the impression, that 2 things are happening:
A) An overload of regulations/must-do's, with the consequence that things start falling off the table.
B) More and more an emphasis on "regulations and must-do's", with the consequence, that pilots become hesitating to "follow their guts" to solve an issue.

This not so much being a flying industry only issue. It happens everywhere, that people no longer dare to solve an issue, but revert to "not in my playbook, so I don't (or I am not allowed to) do".

An example of what happened some years ago in GA, with a C172, a highly experienced pilot. Flying at 2000ft towards a controlled airport, clouds come in unexpectedly with heavy winds and the aircraft getting "VFR on top". The airport was still visible in perfect VFR weather. So, the best option would have been, stay VFR on top, IE fly higher than the normal height for the VFR route in the controlled airspace to the airport. But, that implies, asking permission, and investigations, and potentially a fine. The pilot decided to descent through IMC to expected VDR weather below the clouds. Unfortunately, the clouds were fog, all the way to the ground and the aircraft did a CFIT (and, explicitly, no Loss of Control). 4 People dead, just because the pilot selected to do what could not be registered as an offense and avoiding getting asked nasty questions, etc.

viking767
13th May 2022, 08:18
The 1009 hour figure is obviously an error. The relief pilot is required to have an ATPL with a 757/767 type rating,

Chronic Snoozer
13th May 2022, 12:01
A) An overload of regulations/must-do's, with the consequence that things start falling off the table.
B) More and more an emphasis on "regulations and must-do's", with the consequence, that pilots become hesitating to "follow their guts" to solve an issue.


This. Lawyers and managers in cockpits.

alf5071h
13th May 2022, 14:24
This thread is an example of how language can frame issues, biasing opinion, leading inappropriate conclusions.
The thread title ‘757 Near Stall’ does not relate to the safety investigation referring to speed monitoring.
Total flight hours is falsely equated to experience, whereas experience relates to prior exposure to a situation or similar, and embedding that in memory with focussed learning, understanding and relevance.

The outcome of this event was success; a safe landing. The safety issue is with speed awareness and subsequent flight handling.
Previous incidents and more general speed-AT issues suggests some auto-flight complacency. If repeated events are specific to an aircraft type then consider the technology - dated certification, assess if this is compatible with modern environment, training; consider modification. Crews cannot be expected to manage every system weaknesses in every situation, all of the time.

Re recovery; with situation recognition the injuries resulted from aggressive control. With hindsight this maybe judged inappropriate, but the reaction could have been ingrained by training and SOPs requiring urgent aggressive response to low speed or upset events. The point at which the stall / upset recovery no longer applies has to be judged by the crew, but without alternative other than to ‘fly the aircraft’. Judgements are relative, they are not clearcut decisions defined by procedure, and thus should not be criticised after the event. The crew acted as they saw the situation and as required by their recall of training; the points of safety involve what contributed to the situation and crew behaviour.

[For further debate, would a correct, aggressive upset recovery from wake turbulence, with cabin injury, be assessed in the same manner.]

If the satisfaction of blame is still required then consider how crews are trained for unexpected situations, how they are expected to manage technological deficiencies - situations which have probably been seen by others beforehand, but not reported. A professional approach seeks perfection, but rarely acknowledges the human limitation, that we have done our best but circumstance outwitted us.

vilas
13th May 2022, 15:53
This incident has two straight forward reasons. First is ignorance of the the not so smart or perhaps not very necessary THR HOLD function. And second is lack of proper instrument scan. Speed and altitude requires frequent look over whether with or without AP. A320 accident in 1980 Bangalore is simply mirror reflection of the SFO. Airbus ATHR is non moving thrust levers while B777 has tactile feed back through moving throttles but failed to notice that they were at idle all along. Both accidents nobody monitored FMA or speed. In Bangalore speed reached 26kts below Vapp, in SFO it reached 31kts below Vapp. with similar results.

Axerock
13th May 2022, 16:46
Based on the move of the Tibet A-319 postings - Shouldnt this be moved to the Non airlines / accidents and close calls forum as well?

alf5071h
13th May 2022, 17:37
vilas,
First how can you explain knowledge of the extent or quality of the crews ‘ignorance’.
Unlikely, pure speculation based on your assessment of the event with hindsight. False reasoning from the outcome, backward to deduce cause … Not so.

How many similar events have been encountered without a problem.

Second, how can you know the quality of the crews instrument scan; presuming that you were not there nor have discussed the issue with the crew.

Hindsight bias; https://thedecisionlab.com/biases/hindsight-bias
Individual effects -
… If we look back at past decisions and conclude that their consequences were indeed known to us at the time (when they weren’t), then it makes sense that we will overestimate our ability to foresee the implications of our future decisions. This can be dangerous, as our overconfidence may lead us to take unnecessary risks. …

Also see the related biases: Regret Aversion (https://thedecisionlab.com/biases/regret-aversion), Cognitive Dissonance (https://thedecisionlab.com/biases/cognitive-dissonance), Dunning–Kruger Effect (https://thedecisionlab.com/biases/dunning-kruger-effect)

tdracer
13th May 2022, 17:58
I am wondering about the parallel universe where 186 kts is a dangerously low airspeed requiring aggressive intervention

I've been wondering the same - 186 kts doesn't sound dangerously slow to me. More like the PF was distracted then startled when he realized they were approaching stall and shoved the wheel forward.
Did they get a stick-shaker, or did the pilot just realize they were going way to slow?

vilas
14th May 2022, 05:34
vilas,
First how can you explain knowledge of the extent or quality of the crews ‘ignorance’.
Unlikely, pure speculation based on your assessment of the event with hindsight. False reasoning from the outcome, backward to deduce cause … Not so.

How many similar events have been encountered without a problem.

Second, how can you know the quality of the crews instrument scan; presuming that you were not there nor have discussed the issue with the crew.

Hindsight bias; https://thedecisionlab.com/biases/hindsight-bias
Individual effects -
… If we look back at past decisions and conclude that their consequences were indeed known to us at the time (when they weren’t), then it makes sense that we will overestimate our ability to foresee the implications of our future decisions. This can be dangerous, as our overconfidence may lead us to take unnecessary risks. …

Also see the related biases: Regret Aversion (https://thedecisionlab.com/biases/regret-aversion), Cognitive Dissonance (https://thedecisionlab.com/biases/cognitive-dissonance), Dunning–Kruger Effect (https://thedecisionlab.com/biases/dunning-kruger-effect)
Look if you make an approach without looking at your speed till you crash it's poor flying. It's poor scan. Period. No fancy theories are required. FIrst pilot of Boeing should know the intricacies of THR HOLD. There's a problem in SFO report NTSB asked Boeing to look at it. However it's a case of thrust not moving to maintain speed notwithstanding why. So if the pilot has the scan he will notice and move the thrust himself. Providing fancy human factors for poor flying is the reason for more and more automation. Finally it will take the pilot out.

hans brinker
14th May 2022, 05:41
I've been wondering the same - 186 kts doesn't sound dangerously slow to me. More like the PF was distracted then startled when he realized they were approaching stall and shoved the wheel forward.
Did they get a stick-shaker, or did the pilot just realize they were going way to slow?

Regardless if it was dangerous, the crew selected an airspeed of 250. For the aircraft to reach a speed of 186 means a loss of 64 kts IAS that wasn't noticed or corrected.
That's a safety issue.

BoeingDriver99
14th May 2022, 07:19
Whilst I think Alf understands the complexity behind the human condition better than most; vilas has a simple but correct point - if Speed decays 20-30 knots below Vapp then either the pilots are not scanning/observing the speed or they are and don't comprehend the situation.

One is closer to negligent behaviour and more straightforward and the other is much more complex and involves training, recruitment, fatigue, SOPs, CRM and so on.... So it really then depends on where you place the crew in any incident on that scale and more importantly where their management places them.

DType
14th May 2022, 07:30
Awfully sorry, SLF here (though I have flown in Vampires and Meteors), but it sounds like another case where highlighting AoA would have helped?

SpamCanDriver
14th May 2022, 08:56
Awfully sorry, SLF here (though I have flown in Vampires and Meteors), but it sounds like another case where highlighting AoA would have helped?

The problem was caused by a lack of monitoring the instruments, specifically the Airspeed indicator.
I'm not sure how adding another instrument to the panel would of solved the problem

Uplinker
14th May 2022, 10:54
Agree. A lack of instrument scan, simple as that. Pilot 101.

This crew obviously did not monitor their airspeed. Had they noticed the decaying speed, all they had to do in a Boeing - in any aircraft for that matter - was manually push the thrust levers forwards.

If the speed starts dropping, I glance at the engine N1 or EPRs, and I expect to see the auto-thrust bring the engines up to correct it. If auto-thrust doesn't react I do something about it.

If the automatics are not doing what is required, you step in and reselect or take over.

Unless, maybe the thrust levers both became physically jammed at idle and both crew struggled to release them as the speed decayed, but we haven't heard anything along these lines.

42go
14th May 2022, 13:28
Also see the related biases: Regret Aversion (https://thedecisionlab.com/biases/regret-aversion), Cognitive Dissonance (https://thedecisionlab.com/biases/cognitive-dissonance), Dunning–Kruger Effect (https://thedecisionlab.com/biases/dunning-kruger-effect) For all the grand science, Alf, it is called 'cock-up' by pilots.

tdracer
14th May 2022, 19:42
Regardless if it was dangerous, the crew selected an airspeed of 250. For the aircraft to reach a speed of 186 means a loss of 64 kts IAS that wasn't noticed or corrected.
That's a safety issue.
You're missing my point. Not in any way excusing allowing airspeed to drop 64 kts before taking action - just wondering why that action was so aggressive that it injured people in the back - flinging the flight attendants into the ceiling.
Seems a gentle forward push along with advancing the thrust levers would have been more than sufficient to prevent the aircraft falling out of the sky.

Newcomer2
14th May 2022, 20:25
Also, who selects LVL CHG to correct 100ft?
V/S would be a lot more appropriate...

hans brinker
14th May 2022, 20:27
You're missing my point. Not in any way excusing allowing airspeed to drop 64 kts before taking action - just wondering why that action was so aggressive that it injured people in the back - flinging the flight attendants into the ceiling.
Seems a gentle forward push along with advancing the thrust levers would have been more than sufficient to prevent the aircraft falling out of the sky.

They messed up twice, getting in and getting out.
I haven't flown the 757, but guess min clean would be around 210 ( based on Vref30 + 80 kts and Vref135kts, found on the internetz, FWIW).
I do think that when you get 25 knots below your minimum speed swift action might be required, so I still maintain the first part was the bigger problem.

DaveReidUK
14th May 2022, 23:05
You're missing my point. Not in any way excusing allowing airspeed to drop 64 kts before taking action - just wondering why that action was so aggressive that it injured people in the back - flinging the flight attendants into the ceiling.

I guess the combination of being furthest from the CofG,and not strapped in, isn't in your favour.

BoeingDriver99
15th May 2022, 05:39
Perhaps the poorly handling pilot (PHP?) was startled and reacted thusly?

I would hazard a guess and say the pilots were physically looking at the instruments but not actually 'seeing' or understanding what they were seeing. So it's a tad more complex than 'c0ck-up' fellas....

fdr
15th May 2022, 05:57
The data is pretty depressing... the reports are abysmal to pitiful.

For a considerable time, the crew appear to have been preoccupied with tasks other than monitoring the performance of the aircraft relative to desired targets. The closest the aircraft got to an aerodynamic stall was in the middle of the inputs by the pilot which become pretty uncoordinated to the required aircraft attitude necessary to recover the aircraft from the low-speed case back to the desired speed. The aircraft was never in any particular danger, it was merely at an undesired speed, and the injuries were directly related to the excessive response by the PF.

Fatigue would add to the lack of recognition of the condition of the aircraft, and to the response being uncoordinated to the need of the situation. Presumably, this is an early morning departure ex Scotland, given the event occurred at 13:00 CDT. (16:47:30UTC, first response by crew). The crew rest before the flight may have added slightly to the actions, but 3, crew, daylight flight, after some form of local rest.... not directly a big red flag on fatigue risk management.


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VH-MLE
15th May 2022, 06:04
As DaveReidUK suggests, those (unrestrained) towards the rear of the aircraft are more likely to be thrown about due to the longer levering arm towards the rear of the aircraft. A similar incident occurred with Qantas around 5 years ago - this is an extract from the ATSB report...In-flight upset involving Boeing 747-438, VH-OJU, 110 km SE of Hong Kong Airport, on 7 April 2017Contributing factors

After overwriting the hold speed in the flight monitoring computer , the flight crew did not identify the need to re-evaluate the hold speed for the higher than expected hold level.
Prior to entering the hold, the aircraft’s speed reduced below both the selected and minimum manoeuvring speeds. The crew did not identify that the aircraft was operating below these speeds.
The reduced speed coincided with the turn to enter the holding pattern and the level capture. These factors resulted in pre-aerodynamic stall buffeting and probable stick shaker activation.
The pilot flying attempted to arrest the rate of descent prior to completing the approach to stall actions. The pilot monitoring did not identify and call out the incomplete approach to stall recovery actions. These combined actions led to pilot induced oscillations and further stick shaker activations.
The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle. (Safety issue)
The passenger in seat 63C was not wearing a seatbelt at the time of the stick shaker activations.

VH-MLE

BoeingDriver99
15th May 2022, 09:44
The interviews with the crew are interesting to read - such a normal day for all three pilots and then it all went very wrong, very quickly.

What it makes me wonder is how often events just like this occur but the crew save themselves a whisker sooner and don't get the NTSB involved? Is it a one off or the tip of an iceberg of inattention?

BoeingDriver99
15th May 2022, 09:50
Also.... isn't this a reasonably close "Close Call"?

vilas
15th May 2022, 11:20
As DaveReidUK suggests, those (unrestrained) towards the rear of the aircraft are more likely to be thrown about due to the longer levering arm towards the rear of the aircraft. A similar incident occurred with Qantas around 5 years ago - this is an extract from the ATSB report...In-flight upset involving Boeing 747-438, VH-OJU, 110 km SE of Hong Kong Airport, on 7 April 2017Contributing factors

After overwriting the hold speed in the flight monitoring computer , the flight crew did not identify the need to re-evaluate the hold speed for the higher than expected hold level.
Prior to entering the hold, the aircraft’s speed reduced below both the selected and minimum manoeuvring speeds. The crew did not identify that the aircraft was operating below these speeds.
The reduced speed coincided with the turn to enter the holding pattern and the level capture. These factors resulted in pre-aerodynamic stall buffeting and probable stick shaker activation.
The pilot flying attempted to arrest the rate of descent prior to completing the approach to stall actions. The pilot monitoring did not identify and call out the incomplete approach to stall recovery actions. These combined actions led to pilot induced oscillations and further stick shaker activations.
The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle. (Safety issue)
The passenger in seat 63C was not wearing a seatbelt at the time of the stick shaker activations.

VH-MLE
This is another as ridiculous as it gets. The combined experience of the three in the cockpit was more than 40000hrs. And they were not sufficiently trained on stall in those 40000hrs. They didn't know the higher level holding speed. You know what? they didn't have to know because it was in the FMS but they overwrote it with faulty thumb rule speed. They kept stalling in the turn because they didn't know the correct recovery procedure or may be they didn't know they were stalling. Thank you! I don't want to know the human factors involved.

fdr
15th May 2022, 12:34
Also.... isn't this a reasonably close "Close Call"?

Nah. Plane never stalled, nothing other than the cabin crew was harmed. It actually was no closer than 10 KCAS to the min speed alert (185.5KCAS min CAS recorded, min manoeuver 174.5KCAS...). It wasn't dangerous from an aerodynamics or dynamics aspect, but the response from the crew was pretty darn "biggly".... didn't need to be, but as an institution, we are pre-priming crews to respond too aggressively to what was otherwise just a bit embarrassing.

If we cannot fly in instruments we have no place being in the sky with clouds;
If we cannot cope with the annoyance of a stall, we have no place being in the air period.


https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/850x738/aaupset10_a501c2bdd4ac810271047620b2c89ea038a9b0b0.png

WideScreen
15th May 2022, 15:11
....... but the response from the crew was pretty darn "biggly".... didn't need to be, but as an institution, we are pre-priming crews to respond too aggressively to what was otherwise just a bit embarrassing.......
Actually, the consequence of the initial pitch response only made the teapot 1.5 times heavier.

The ceiling encounter of the cabin crew, in the back of the airplane, seems to be due to an even more aggressive correction to "undo" the original pitch reaction.

To me, this whole suggests a "firm" reaction to a suddenly detected potentially dangerous situation (IE low airspeed), with a subsequent "relieve", "Oh, it's not that bad". And that relieve reaction got screwed up by a far too aggressive input.

WideScreen
15th May 2022, 15:18
.....
https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/882x738/aaupset_6_58b5738dff5a28b136fc583205970a6857ad2832.png
....

I am trying to understand what Gz stands for: Is this the vert (?) acceleration of the airplane's center of gravity, or the vert (?) acceleration in the back of the airplane ? The latter being the relevant item, judging about what would happen with non-fixed objects in the back of the airplane. Both accelerations can be significantly different, when pitch actions are involved.

DaveReidUK
15th May 2022, 16:40
I am trying to understand what Gz stands for: Is this the vert (?) acceleration of the airplane's center of gravity, or the vert (?) acceleration in the back of the airplane ? The latter being the relevant item, judging about what would happen with non-fixed objects in the back of the airplane. Both accelerations can be significantly different, when pitch actions are involved.

Gz is vertical acceleration at the CofG.

To get a picture of what's happening at the back end, you would need to factor in pitch data.

RatherBeFlying
15th May 2022, 17:31
Gz in the fdr trace will be measured wherever the accelerometer is located. My guess is that it's located in the avionics bay. An abrupt pitch rate will produce opposing Gz rates at the ends of the aircraft.

Once the pitch rate goes to zero, unrestrained objects will tend to continue in the direction they have been accelerated, much like a catapult if in the rear during a pitch down. In front, unrestrained objects in negative Gz will head to the ceiling and drop back down when Gz rate returns to zero, as was demonstrated by an ashtray bouncing off the ceiling when I advised my instructor we were climbing into the path of another airplane on a converging course. He had been questioning my reducing our climb from a practice forced approach.

punkalouver
16th May 2022, 13:27
I disagree that HOLD mode is moronic. What is moronic is the mis-handling or lack of awareness and understanding of the aeroplane systems operation.

On the B777 and B787 the HOLD mode software has now changed in that speed protection, i.e. Autothrottle Automatic Activation, now functions when in that mode. I presume the change applies to other models as well.


I think there are different ways of looking at this. It is nice to say that it is moronic to have a lack of awareness or have mis-handling of a system function and there may be a valid argument for that.

But there is also the reality that it is well known that when there are thousands of pilots around the world flying the aircraft types, who are humans and make mistakes, where weak pilots inevitably will fall through the cracks somewhere, where fatigue will be an issue, where distractions happen, where even good pilots make mistakes, where language barriers result in incomplete knowledge, where instruction may not cover everything as well as it should, where a pilot is close to overwhelmed with knowledge in training........ that it makes sense for a design where autothrottle wake-up exists in most areas but not in another(in HOLD mode) is an incident waiting to happen because someone will inevitably it existed but did not.

It may feel good to yell "you are a moron" but it doesn't make things much safer(in terms of lack of awareness/forgetfulness of the lack of autothrottle wake-up in HOLD Mode). I suspect the modification did.

Fursty Ferret
16th May 2022, 16:08
Also, who selects LVL CHG to correct 100ft?V/S would be a lot more appropriate...

I do. If you use V/S when you're relatively close to your target altitude (~100ft) it'll cheerfully trundle straight on through without capturing, as I've found out through personal experience.

FLCH is easier.

punkalouver
17th May 2022, 13:45
I do. If you use V/S when you're relatively close to your target altitude (~100ft) it'll cheerfully trundle straight on through without capturing, as I've found out through personal experience.

FLCH is easier.

I think V/S works fine. Need to change 100 feet, one could put the V/S at 100 fpm and you would have a full minute to reach that altitude. Perhaps some aircraft have had software issues.

FLCH
17th May 2022, 13:55
FLCH is easier.


Don't be talking about my dating habits……😂

fdr
17th May 2022, 16:35
Gz is vertical acceleration at the CofG.

To get a picture of what's happening at the back end, you would need to factor in pitch data.

True. The vertical g, Gz measurement is almost always offset to the aircraft mean cg or its instantaneous CG, as well as aerodynamic centers. It is strapped down to the aircraft references, so is impacted as well by attitude vs external reference, and the rates will affect the readings dependent on the offset from where the aircraft is actually pivoting in all xis. Convention gives the rotation around the actual CG.... which is not quite true but is near enough for passing a written exam. There are occasions that the aircraft will not rotate around the CG at all, a statement that can start an argument or not, but it is interesting reading, and even more interesting to look at the flight data. One of the most obvious cases of that is a good crosswind, like 45-50kts on a B777 and watch where the alignment puts the cockpit. Other planes behave slightly differently but the rotation is not around the CG. (moment around the CG is what is used in the end for calculations, but the moments are around the AC not CG, so have to be corrected by those offsets to get the moments around the CG.... which is kind of odd, as the AC is generally more stable in position than the CG is).

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/1530x284/screen_shot_2022_05_18_at_1_08_44_am_43f052aadc8dc0c29293c08 51de82e26e9502c25.png
where:

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/1450x736/screen_shot_2022_05_18_at_1_11_43_am_751eda72d37d2502b2b22df 9b3bcead86777eec1.png




Anyway,

This case, the aircraft had a mild pitch up approaching the min soeed case, as the AP was atttempting to respond to the commended mode of the crew, as speed reuduced. (forget about the fact that the plane had already been cleared to a lower level, so the vertical mode is pretty much irrelevent, it is just options). As it got to peak pitch of just under 10 degrees, at 184.5kts, it then started to pitch down, at around 6 degrees a second, 0.1rad, and recorded a Gz lowest of -.025g +/-, which would have an actual almost zero g loading at the aft galley... Thereafter there was a pitch recovery and a return of the Gz towards normal levels.

WideScreen
17th May 2022, 17:42
Gz is vertical acceleration at the CofG.

To get a picture of what's happening at the back end, you would need to factor in pitch data.

Gz in the fdr trace will be measured wherever the accelerometer is located. My guess is that it's located in the avionics bay. An abrupt pitch rate will produce opposing Gz rates at the ends of the aircraft.
Now, we do have 2 different definitions, which one is the correct one ?

Once the pitch rate goes to zero, unrestrained objects will tend to continue in the direction they have been accelerated, much like a catapult if in the rear during a pitch down. In front, unrestrained objects in negative Gz will head to the ceiling and drop back down when Gz rate returns to zero, as was demonstrated by an ashtray bouncing off the ceiling when I advised my instructor we were climbing into the path of another airplane on a converging course. He had been questioning my reducing our climb from a practice forced approach.
Yeah, happens with negative g.

WideScreen
17th May 2022, 18:21
......

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/1530x284/screen_shot_2022_05_18_at_1_08_44_am_43f052aadc8dc0c29293c08 51de82e26e9502c25.png
where:

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/1450x736/screen_shot_2022_05_18_at_1_11_43_am_751eda72d37d2502b2b22df 9b3bcead86777eec1.png




......
Some questions about the formula/diagram:
- LWBN and LT do seem to have the same direction, whereas I would expect the LT to be downward in the diagram, otherwise the sign in the formula should be different. Just like TZT and TZD do have different signs in the formula. So, I think, it works out fine, though it's confusing.
- The Datum location is irrelevant for Moment calculation, as long as there is no rotation, though once rotation sets in, it needs to be in the rotation point, to let the Moment calculation work. The formula does suggest a general purpose validity, and does not suggest a zero angular velocity/acceleration. Correct ?

Skittles
21st May 2022, 21:42
Did we enter some sort of parallel universe a few years ago - one in which pilots don't know how to fly, or scan their instruments? :confused:

Absolutely.

There were in fact no aircraft accidents in history prior to 2015, and no recorded occurrences of pilot error.

vilas
22nd May 2022, 06:30
Absolutely.

There were in fact no aircraft accidents in history prior to 2015, and no recorded occurrences of pilot error.
Ha!Ha Yes! Those pilots were in garden of Eden.​​​

alf5071h
22nd May 2022, 09:42
“… some sort of parallel universe a few years ago - one in which pilots don't know how to fly, or scan their instruments?”
“… no aircraft accidents in history prior to 2015, and no recorded occurrences of pilot error.“

‘Safety’ depends on context, the viewpoint, as chosen by the observer.
‘Safety’ as something to have, to be; or as all of the activities undertaken every day, and not as imagined.

‘A Statistical Analysis of Commercial Aviation Accidents 1958 - 2021’
https://accidentstats.airbus.com/sites/default/files/2022-02/Statistical-Analysis-of-Commercial-Aviation-Accidents-1958-2021.pdf

https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/320x178/8449dddf_40e3_4fe1_a786_79ab399f19e1_24611ef6dee046cbbc1ddae d7427e3004fc79c03.jpeg

Page 17

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/320x178/ebaf6681_c77b_4c88_a79c_2ce1d6254332_3ba51b748606f01ff5f5d9d 058563b7c76e3b578.jpeg

Uplinker
22nd May 2022, 12:10
Oh, OK then. So nobody else is worried that supposedly trained and qualified pilots - even Captains - are crashing or nearly crashing because of very very basic piloting mistakes or omissions?

Fair enough.

fdr
22nd May 2022, 12:38
Oh, OK then. So nobody else is worried that supposedly trained and qualified pilots - even Captains - are crashing or nearly crashing because of very very basic piloting mistakes or omissions?

Fair enough.

nah, your concerns are shared by quite a few.

ALF5071H makes a valid observation that over time flight safety has improved markedly, and that is true, the concerns and the historical improvements are not mutually exclusive.

Aviation systems of display, alerting, warning, and design have improved greatly over time, yaay. Planes don't fail structurally as they used to do, and pilots don't get lost as often as they did.... What we are left with exposes the obvious issues of crew-centric matters, both good and bad. Whether basic competency has altered over time is not confirmed, the weighting of events that competency is questioned is more evident. Even without empirical proof that there is a change, that a children of the magenta really is a factor, the system response to the residual events remains inadequate.

alf5071h
22nd May 2022, 16:17
Further observations from the safety statistics.

A comparison between different generations of aircraft strongly suggests that technology has improved safety. However, as the new generation aircraft are still crewed in the conventional sense, then the technology and associated training will have reduced the human contribution in incidents. There are fewer accidents overall, the human contribution has reduced, i.e. pilots of gen 3-4 aircraft appear more capable - better matched competency - the combination of man and machine.

Exceptions would be in older generations where there are many gen 3 aircraft which were designed as gen 2, but with system updates pretend to be gen 3; e.g. B 737, F100, ARJ, and B 757.

The perceived training and proficiency issues in current operations with older generation aircraft could be due to crews being exposed to other factors, e.g. older aircraft in a new aircraft operational environments.

Also that safety management has moved away from accidents (very few of them), to focus on events, which previously could have been accepted as normal, and not necessarily ‘unsafe’ depending on outcome.
Modern aircraft with event auto reporting or FDR analysis might proportionately identify more safety events, but are not less safe because of knowledge and investigation.
Operations without reporting could experience the same event, remaining unknown, similarly not less safe.

The industry assumes too much about the human contribution, the ability to manage changes in design, training, and operation, particularly in older aircraft; there is a mismatch in man-machine (and operational situation) competency where substandard operation is inappropriately focussed on the human.

Safety is not so much about where a line is drawn it depends on who draws it, interpretations, judgement after fact.

Bergerie1
22nd May 2022, 16:46
Can somebody check my maths (never one of my strong points), but looking at the graph on page 14 in the link, in 1961 there were 9 hull losses per year and around 1 million flights. In 2017, there were 35.8 million flights per year. If the same accident rate had persisted, there would have been 346.5 hull losses in 2017 https://accidentstats.airbus.com/sites/default/files/2022-02/Statistical-Analysis-of-Commercial-Aviation-Accidents-1958-2021.pdf

A stunning improvement by any measure even though there remains much to be done to improve crew training. Any thoughts or corrections?

punkalouver
23rd May 2022, 04:25
Bottom line. On occasion, there is an issue where the aircraft is not maintaining the desired airspeed despite the pilots expecting it to do so. On rare occasion, this will happen during the briefing. On even rarer occasion, the pilot who is receiving the briefing while flying the aircraft will not be properly monitoring the airspeed.

Therefore, I suggest that the pilot doing the briefing make occasional, quick glances at the instruments while giving the briefing. Every 30 seconds or so might work out well as a good balance beteeen briefing and double checking.

Admittedly, one may be less vigilant when briefing during the cruise phase of flight, but vigilance should definitely be increased anytime a briefing is happening after top of descent.

Herod
23rd May 2022, 10:29
punkalouver. I love your suggestion that pilots should check the instruments every so often while briefing. Whatever happened to "check; cross refer; check again"? Something I remember from famil 1, which in my case is some 57 years ago.

punkalouver
23rd May 2022, 11:42
punkalouver. I love your suggestion that pilots should check the instruments every so often while briefing. Whatever happened to "check; cross refer; check again"? Something I remember from famil 1, which in my case is some 57 years ago.

I think it will be effective. When I see incidents happen, I am interested in solutions that a pilot can use to prevent it from happening again. Comments about how pilots are not as good as they used to be or sometimes the frequent blame management idea provide little to no assistance to the pilot pilot interested in a solution for their next flight.

fdr
23rd May 2022, 16:06
Can somebody check my maths (never one of my strong points), but looking at the graph on page 14 in the link, in 1961 there were 9 hull losses per year and around 1 million flights. In 2017, there were 35.8 million flights per year. If the same accident rate had persisted, there would have been 346.5 hull losses in 2017 https://accidentstats.airbus.com/sites/default/files/2022-02/Statistical-Analysis-of-Commercial-Aviation-Accidents-1958-2021.pdf
A stunning improvement by any measure even though there remains much to be done to improve crew training. Any thoughts or corrections?

The 60's and 70's were brutal for plane losses. The temporal change and basic nav and displays were not conducive to safety. Early jets and fanjets were quickly more reliable than big pistons and turboprops, but the performance changes challenged the training and alerting systems. As alerting and SA systems improved, the crew coordination and decision-making became evident as problems, and post Portland and the Everglades, coordination seemed to get a boost in emphasis.
The concern in the early 70's was that the rates of losses were so high that the expected expansion of global aviation would result in unacceptable headlines every day, as you indicate. EGPWS/TAWS/TCAS/EFIS/ECAM-EICAS/GNSS etc helped, and additional protective warning modes were added to warning systems, which also became conditional to assist the crew in making appropriate decisions.

The crew have been losing control of aircraft since the start of aviation, the concern remains that loss of control generally results from a failure of SA and we have much more advanced tools for the crews to mitigate that yet it continues. The losses in most cases make depressing reading with very few novel manners of losing the plot being disclosed. The HITL is still the current most effective way of mitigating the gap between planned design behavior and system reliability. Automation inherently places the human into a process that they are less effective at over time, that of monitoring, and frequently that is a primary factor in the divergence from the desired state to the actual state. The recovery from an anomalous state often is at the end of the spectrum of responses from nothing or inadequate through to excessively aggressive with possible adverse consequences, e.g., Lauda's TR event was time-critical, AA587 needed a gentle response, both events had critical information that was not self-evident before the event which in hindsight resulted in changes to procedures. SR111 is another case where there was a mismatch of procedures and needs, which generated some changes post-event.

Competency in dealing with recognition of time-sensitive anomalies is a challenge but offers potential relief from such things as 260 kt low flying on takeoff, or wild rides in recovery from upsets.

Much like the '70s. management needs to look to new initiatives to reduce the residual events severities that exist now with current aircraft operations. Some stuff will remain depressing, like the turning off of all IRS's in IMC conditions... hard to mitigate unfathomable actions. Deliberate unlawful actions by the crew need more response than has occurred to date, and remain a blight on the industry. Post 9/11, the compliance with security protocols when audited varied from excellent to patchy, so protection from crew-caused illegal actions could also be variable depending on how seriously mitigation protocols (if any) are taken.

james ozzie
23rd May 2022, 19:21
As a boss of mine once said: "Gentlemen, I want to see NEW mistakes".

hans brinker
24th May 2022, 00:09
As a boss of mine once said: "Gentlemen, I want to see NEW mistakes".

I know this is a serious subject, but yeah. Definitely had a laugh. Can just imagine the pilots going:" No Nigel, Henry did that last year!"

Uplinker
24th May 2022, 09:44
punkalouver. I love your suggestion that pilots should check the instruments every so often while briefing. Whatever happened to "check; cross refer; check again"?..........

But you do look up from the plate or MCDU and glance at the PFD and engine instruments every so often as you brief - (even though you are on automatics) - surely?

Bergerie1
24th May 2022, 09:54
Would it not be better to do your briefing when in the cruise shortly before top of descent when everything is quiet? That way it would be much easier to 'mind the shop' while going through the charts and plates. Then, only minor updates would be necessary later. Much better to plan ahead and sequence activities to avoid peaks of workload and/or distractions. A counsel of perfection I know but it can be done.

punkalouver
24th May 2022, 14:08
But you do look up from the plate or MCDU and glance at the PFD and engine instruments every so often as you brief - (even though you are on automatics) - surely?

As a matter of fact.......Yes(at least for for PFD). Perhaps ND as well, especially when one is briefing in the terminal area. Does this not seem logical?

Remember something. When the PF hands over control to start briefing, he has become the PM(Pilot Monitoring). Why would you stop monitoring whether it is while briefing or eating or filling out the logbook, etc.

FlightDetent
24th May 2022, 14:32
WTHeck are we discussing here, sounds like the widebodies have a dedicated and separate briefing classroom or what? And 757 ain't one.

Uplinker
24th May 2022, 18:29
@ punkalouver; exactly. Of course the main approach briefing should be completed before TOD. Not doing so was their first hole in the cheese.

Not monitoring the aircraft or the instruments was their second.

tzuris
24th May 2022, 20:16
It's just too easy to be a keyboard warrior. Thousands and thousands of safe flights everyday so I don't think it's appropriate to deduce from isolated incidents that pilots these days don't know how to scan and fly. Lessons to be learned for sure but no need to dramatize and generalize, I think.
Remember Air France 447? Where the pilots couldn't recognize a stall - one of the first lessons taught all new student pilots.

InnerLoop
24th May 2022, 21:00
@ punkalouver; exactly. Of course the main approach briefing should be completed before TOD. Not doing so was their first hole in the cheese.

Not monitoring the aircraft or the instruments was their second.
Agreed with the above. But. There will always be the potential to be squeezed on time for the briefing because some unforeseen thing came up to be dealt with (or a bunch of small ones) before TOD.
And there will will always be the potential to have a lapse in monitoring, and/or some cascading mode confusion, where when you finally "reconnect" with the airplane, the speed (or some other parameter) is not at a good spot. We can (and should) be as diligent as possible with the time management, and with monitoring, and with mode awareness, but none of this makes for a surefire catch-all trap for all situations that may be encountered.

There must still be the outermost layer to trap the bad situations that leak through: the comfort and ability to fly the airplane, that allows someone to calmly lower the nose a few degrees (to the 2000 feet lower altitude they were cleared to) without panicking and shoving the yoke and having a PIO that injures flight attendants. And there is only one way to ensure this comfort and ability as a baseline state.

punkalouver
25th May 2022, 02:14
@ punkalouver; exactly. Of course the main approach briefing should be completed before TOD. Not doing so was their first hole in the cheese.

Not monitoring the aircraft or the instruments was their second.

Millions of flights happen each year. It is inevitable that a runway change will happen or a new STAR, etc. It is not necessarily an error to end up making a briefing after top of descent. I don't know what happened in this incident but I doubt they just waited until a fairly low altitude to start the briefing. It is more likely that the first mistake was not monitoring their instruments, which should be done by the briefer as PM.

Uplinker
3rd Jun 2022, 18:18
Both pilots should be monitoring the 'plane.

Yes, of course there will always be runway changes, requiring a condensed re-briefing below TOD, but the implication that both or all pilots will be head down, engrossed in the plates and not regularly glancing at their PFD is what I find so difficult to understand about this incident - especially during a significant change such as a level off.

You put the plate down for a moment and watch the automatics capture the new FL and the thrust levers come up, then continue.

Pugilistic Animus
4th Jun 2022, 23:28
Interesting that the pilot with 1009 hours TT was the telling the pilot with13.000 hours in type what to do.

That should be well covered in your CRM course from your company...