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ATSB report just published on A320 throttle asymmetry incident

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ATSB report just published on A320 throttle asymmetry incident

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Old 25th Jan 2013, 02:58
  #21 (permalink)  
 
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Read the report 10 times. I'm not looking forward to my A319 endo!

I think more plain language from training captain was in order, and/or just push up the throttles to TOGA himself. "Thrust asymmetry, selecting TOGA" or similar.

"Go"? one syllable, easy to mishear?

Good learning experience nevertheless, even for us non-computer types. Good on the crew for reporting it.
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Old 25th Jan 2013, 03:04
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Why airlines dick around with manufacturers recommended procedures and SOP's is beyond me.

The ATSB show again that they cant do any sort of analysis or have any expertise. This is just a regurgitation of an internal Jetstar report it would seem.

Last edited by Rudder; 25th Jan 2013 at 03:07.
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Old 25th Jan 2013, 05:08
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Unhappy OEMs build them - they don't operate them!

Hey Rudder,

What are the "manufacturers recommended procedures and SOP's" that apply in this situation?
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Old 25th Jan 2013, 06:50
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Doesn't matter how experienced you are as an F/O, when you are doing Command training on a new type you are on a steep learning curve and mistakes will occur. The Training Captain can't anticipate every unexpected response if he hasn't experienced it previously
Then this trainee captain IS DEFINITELY NOT READY for command! As has been pointed out, rotating without crosschecking is a no no, especially if there was no prior V1 call.
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Old 25th Jan 2013, 07:12
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Ah, ah, ahhhhhh bullish!t he's not

How did this make it to report stage? Bro in the right seat shoves the throttles full stick, tells bro in the left seat, lower the nose a bit bro, climb, climb, climb. Don't do that again bro! Sorry bro....
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Old 25th Jan 2013, 08:07
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Scrubba,

I don't know what Rudder has in mind but being an Airbus trained TRE/TRI my view is that the SOP's call for a thrust set call by 80 its. If it isn't then a slow speed rejected takeoff would have been more appropriate and required by the SOP's otherwise why have the call in the first place.

From what I read, the Pilot under training was not with the aircraft even at this early stage and the training captain sitting there and hoping this would resolve itself by directions probably is a bit passive. While clearly the Training Captain knew that the thrust was at least forward of the detent and had at least the minimum power expected for this particular takeoff, the guy with his hands on the thrust levers had no idea.

While I clearly think that this takeoff should have been rejected. Another course of action given that the training captain was situationally aware of the power, was as Capt Bloggs indicates and that was to push the lever forward himself to TOGA ASAP and take over.

I have no idea how anyone can get Rotate out of GO TOGA but it does indicate that probably the guy under training was still trying to in fact figure out what was going on and was well behind the aircraft and this is the guy pulling the aircraft into the air!!

Bloggs you will love this aircraft. You just have to give up on Boeing and come across to the dark side!! (Sniggering aside they are really great)
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Old 25th Jan 2013, 08:11
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Never trust an A320 NEVER
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Old 25th Jan 2013, 08:27
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Anti skid on, take off distance is not calculated. Speeds are calculated to fit in with all the factors. Estimating distances is pure guesswork based on familiarity with the runway and conditions. But yes, checking the ASI should very much be part of the scan.

"Go toga" and "Rotate" probably sound similar in the fog of war.
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Old 25th Jan 2013, 10:32
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"Go toga" and "Rotate" probably sound similar in the fog of war.
Maybe so, and impossible to argue against that.

However, why didn't the cognisant lack of a V1 call raise a hair on the back of the PF's neck? Shouldn't the PF have a chronological feel for when the call should be coming from the inertia of the aircraft? 130-150 kts is a fair split and if you "thought you'd missed the call" wouldn't you also be thinking it's a bit early and double check your speed tape?

I assume the speed tape scan was part of the PF's scan? The report doesn't mention the 100kt call though either....

PS. I'm giving the ATSB the benefit of the doubt for the lack of detail in this report due to the fact that the CVR would have been overwritten...

Last edited by compressor stall; 26th Jan 2013 at 03:41. Reason: Grammar. And clarifying intent.
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Old 25th Jan 2013, 12:13
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With the 737 there is a 80 knot call and with Airbus there is a 100 knot call. The principle as far as I know is a check that both ASI's are within a bull's roar of each other. In other words guarding against a gross error. A wise man will know the wind velocity before the start of the take off run and by association the expected ground speed read-out at the 80 or 100 knot call for the aircraft type.

As a general observation it is probable that an experienced simulator instructor will see more events or incidents in one week while training various ranks of pilots than most line pilots would see in 20 years. So the opinions following are the result of watching years of "events" with erroneous airspeed during type rating and general simulator training.

It takes less than one second to glance at the ground speed indicator during the take off roll at the support call of 80/100 knots. That is of course if you know exactly where the ground speed indicator is located on the instrument panel.

You can never know if a hidden defect is present giving erroneous airspeed. It could be on the take off roll which is critical - or some other time. Indeed, a reminder of this fact may be found in the B737 FCTM where there is a statement "ground speed information is available from the FMC and on the instrument displays (as installed). These indications can be used as a cross-check."

A year or so ago ATSB published an incident report to an A330 on take off at Brisbane with the F/O as PF. I don't recall the exact details but I think there was an insect stuck in the captain's ASI which had the effect of causing his ASI to under-read by a significant amount. Passing 100 knots the F/O expected a support call of 100 from the captain but didn't get one. He said nothing assuming the captain had been distracted and forgot to make the call. Approaching VR on the copilots side and as the copilot was preparing to rotate, the captain called "100 knots". There was immediate confusion as you can imagine. After a very brief moment the captain took control and made high speed abort. Back at the gate the fusible plugs let go as the brakes were hot.

In the Boeing FCTM there is a statement under the general heading of "Callouts" and says "The PM makes callouts based upon instrument indications or observations for the appropriate condition. The PF should verify the condition/location from the flight instruments and acknowledge. If the PM does not make the required callout, the PF should make it."

That is why it is good airmanship for the PF to call something like "95 knots my side" if he didn't get the call of "80 Knots" from the PM. The high speed of the abort by the Brisbane A320 might have been avoided if the PM (the F/O in this case) had called "110 my side" during the take off run instead of saying nothing. While 100 knots was the SOP call here by the time the PF has reacted to no support call by the PM the aircraft would likely have been 10 knots faster - hence the theoretical "110 my side" call by the PF. That would have alerted the captain to a potential problem and he would have to decide to take over and abort or tell the PF to keep going especially as an erroneous airspeed defect is not normally a reason to make a high speed abort.

This then leads us to the value of the ground speed glance where in this case the PF could have quickly noted his ground speed as he passed 100 knots. Having already had in his mind what the ground speed should read approximately as he saw his own IAS going through 100 knots he would be in a good position to know his own ASI was good in event of an erroneous airspeed rare event. In fact there was an erroneous airspeed event on the captain's side - so these things can happen albeit at an unexpected time and very rarely. But that is what good airmanship is all about.

In the simulator an instructor may select a 25 knot airspeed over-read or under-read on one of the two pilots ASI's. Example follows: Captain as PF has the over-reading error but doesn't know about it of course as he starts the take off run. His ASI comes off the stops early and soon rockets past 80 knots. The PM will not know of course. The captain doesn't receive the expected support call from the PM of "80 knots" (Boeing). He quickly calls
"90 my side". The astonished PM mentally thinks "Bull****" as his ASI is around 55-60 knots. He says something out aloud about airspeed disagreement and by this time the aircraft is rapidly accelerating through 100 knots real airspeed.

The captain realises there is an erroneous airspeed problem but there is no time to glance at the standby ASI and evaluate the umpire. Now he could have picked up the problem earlier if he was in the habit of glancing at his ground speed as he passed 80 knots IAS. With his over-reading airspeed he would have been a bit shocked to see his ground speed was something like 50 knots. Providing as a good captain he knew what the W/V was before the start of the roll, he knew the airspeed of 80+ and the GS of 50+ didn't compute and it would then be up to him to continue or stop. He could rotate at the scheduled VR speed on his ground speed reading (allowing for wind component) and at a safe altitude sort out the problem in the air.

This technique taught in the simulator is invaluable and once the crew get into the habit of ground speed awareness because of simulator practice then it becomes second nature for all future take offs. Honestly it is no big deal. But it is a real big deal if a premature action is taken to make a high speed stop simply because of a perceived airspeed difference between the two main ASI's in the middle of the takeof run.

One Pprune contributor in this thread scorned use of the ground speed indication on very short final as useless. In fact those pilots who have flown into some of the atoll runways like Nauru, Tarawa, Truk, Pohnpei and the like will remember the unreliability of local anemometers and at night the windsocks may be unlit. In fact years ago, we had the situation at one island airport the flight service operator announced the wind as calm by simply looking at the forecast wind. His anemometer was u/s and some vandals had shot out the windsock lights. We were on final approach at night at 5 miles and kept a wary eye on the ground speed which showed a 15 knot tailwind from 10,000 ft down. "Wind calm - runway clear" said the local in the flight service tower. That didn't tie in with on course on the VASIS rate of descent. At 500 ft the ground speed was now 10 knots tailwind. The runway was just 5600 ft long and no way were we going to land with any TW so we went around and landed from the opposite direction. It was good to see a 10 knot HW component on that runway.

Morale of that story? Be fully aware of the ground speed indications that may alert you to unforecast or actual tailwinds. Nothing wrong with a quick glance at the ground speed at 200 ft on short final. Especially with varying winds. Similarly on the take off run be aware of the expected ground speed indication as the PM makes his IAS support call for the aircraft type. This could prevent an unwarranted high speed abort because of perceived airspeed reading difference.
Please note: The above comments are personal opinion only. Arguments against should preferably be based on technical disagreements - not playing the man!

Last edited by Centaurus; 25th Jan 2013 at 12:26.
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Old 25th Jan 2013, 13:18
  #31 (permalink)  
 
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Thumbs up

Great stuff Centaurus.
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Old 25th Jan 2013, 22:00
  #32 (permalink)  
 
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Just as a matter of interest, what inputs are used to calculate ground speed and will it still read correctly if the ASI is in error?
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Old 26th Jan 2013, 02:07
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RTO for thrust mismatch

Thanks d_concord,

I thought the TLA mismatch was surprisingly small to cause this problem and even more surprised that the ATSB made no comment about the apparent sensitivity. For the non-Airbus people, I was also disappointed that there was no discussion of what the available solutions were - I'm guessing that repositioning the TLs is not an option, but I'm also surprised that it is not an option up to a certain point in the TO sequence.

I'm unclear why you seem to think it warranted an RTO. Presumably there is some cross-check of engine parameters to confirm that at least flex thrust is being generated - so if it is available, why not continue? Can normal autothrust be reinstated airborne at a safe altitude? Is manual thrust setting difficult or are automatic features disabled with the A/T?

FWIW, I am particularly glad that it was reported, investigated and published. I thought that a lot more could have been drawn from the event and the lead up to it, as well as the company SOPs, preparation of training captains, etc and what reviews took place post-event.

For those who have never suffered a loss of SA by a distraction at a critical time while under the duress of training, don't be so quick to judge - I've seen some very good pilots do some very unexpected things in similar circumstances and everybody was much better for understanding the experience.
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Old 26th Jan 2013, 02:23
  #34 (permalink)  
 
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Some very good points Centaurus. I cannot disagree. However you said...
One PPRuNe contributor in this thread scorned use of the ground speed indication on very short final as useless.
That would be me, for the record what I said was...
Scanning groundspeed for rotate point is about as useful as scanning groundspeed at 100' agl on final.
My bolding this time around. Your point about "trusting' ground reports of wind is one I take to work everyday. Looking for GS for me is not the solution or really required, simply glancing at the wind vector arrow does the trick GS is only part of the story ie is it a quartering tailwind vs headwind etc.

I still feel that scanning GS on the TO roll is problematic, partly due to update rates on the particular box, small as that may be in the scheme of things but mainly due to the small window between "power set" and "V1" to scan all the other useful stuff. Anyway, each to their own.

Last edited by Icarus2001; 26th Jan 2013 at 02:24.
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Old 26th Jan 2013, 03:19
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For those unfamiliar with airbus, the GS comes from the GPS through the inertial reference system. It's displayed at the top of the Nav display.
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Old 26th Jan 2013, 04:41
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Hi Scrubba,

The thrust TLA can be just a millimetre out of the detent to give this indication on the FMA. It will give this whether one thrust lever is forward of the detent or behind as well. The Levers are just a slide switch so position is everything.

What happened here is not unusual. I have seen other do it and have done it myself. And as you say, in all the cases I have seen or done myself you just put the lever instantly back into to the detent and presto now you have the power you programmed. I have never heard of anyone to just sit there with the problem until now.

This is from the Airbus QRH for the PNF

BELOW 80 kt:
N1 (EPR)CHECK
THRUST SET ANNOUNCE
PFD/ENG PARAMETERS SCAN

You will note it says below 80Kts not a specific speed.

This all takes place almost instantly after the levers have been put into the correct position and the FMA will indicate what has been commanded. This is followed by the PNF confirming that the thrust is set from the engine parameters. This will all happen well before 80 Kts. That is what is unusual here. The reality is the thrust set call normally takes place well before 80 kts. The airbus call is "thrust set" not "80kts Thrust set" or "80 kts thrust not set"

The PNF called "80 Kts. Thrust Not Set" (maybe another issue is why wait till then!)

Its very clear that this was now a non normal take off .

A slow speed RTO is a non event in this case. (That's not the case with a slow speed RTO with an engine out but that is another issue )

To be honest, I just don't think the PF understands the FBW characteristics of the aircraft. If he did he would have instantly known the cause and the remedy.

It is interesting that the findings did not see the need to look at or make any comment on any deficiency in understanding or the need to improve the initial conversion training onto the aircraft. Seems as though they did not even look at the ground course or training syllabus of the organisation that did the training. Given the PF had only 120 hours on type this incident started there.

As Rudder indicated you really have to wonder about the ATSB and the level of experience, skill and analysis.










Last edited by d_concord; 26th Jan 2013 at 04:43.
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Old 26th Jan 2013, 08:17
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A very interesting event that has two distinct aspects. First is the actions of the PNF in the 80-120kt region, second the actions of the PF in rotating @130kts. I think the actions of the PF were dealt with above.

But IMHO the action that started this incident was the non standard call "Thrust Not Set" when it appears that it was. That lead to the PF's confusion.

To follow on from d_concord's comments:

Immediately after the Thrust Levers are moved into their takeoff detent, MAN FLX 62 (or TOGA etc) appears on the screen. But the engine isn't at the Thrust Set stage yet. It also takes longer for the IAEs to get to power than the CFMs.

The required N1 (CFM) or EPR (IAE) is displayed on the screen just to the right of the engine N1 or EPR. Only when these two are matched can you call "Thrust Set". This is to be done before (not always at) 80 knots.


Now back to this incident: From the little information available, it would appear that the thrust was indeed matched between that commanded by the TLA and that required (it should have exceeded it, but we aren't told this ) . As such the correct call would have been "Thrust Set" even if there was a MAN THR displayed on the FMA. in this case, the FMA has nothing to do with the Thrust required, which is the purpose of the thrust set call.

The correct call (in addition and either before or after the Thrust Set call as noticed) should have been reading the FMA - "Manual Thrust".

Then if was all still going to custard which is the subject of another debate, Go - TOGA was the correct action (as the thrust was indeed set).


Hopefully this thread can remain a healthy discussion here with appropriate respect to the pilots involved about an event from which we all can learn.

Last edited by compressor stall; 26th Jan 2013 at 10:00.
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Old 26th Jan 2013, 22:37
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Apples to apples.

Rudder # 23 –"The ATSB show again that they cant do any sort of analysis or have any expertise. This is just a regurgitation of an internal Jetstar report it would seem".
A valid point, well worth some time and consideration. The slippery feel of 2012 report offers little 'meat' compared to the 'food for thought' of 2006 report and very neatly demonstrates the differences we are consistently seeing in ATSB reports.

Airbus 2006.

Airbus 2012.

There is in the GA section a report on an engine failure, at night of a single engine training exercise. The report has a smug, almost patronising feel to it and provides little of value. It arrives at the end of a long string of similar offerings. If you can bear it, have a look at the Air Rescue, Air North, Pel Air and Canley Vale efforts, they are enlightening.

Oh, almost forgot, overheard at the after cricket BBQ – and this is strictly "off the wind"; but it seems some bright spark at CASA has outlawed the "80 knot" cross check call for "light" jets and similar. Remove all traces from SOP or evil will be visited on your house. Only BBQ fuelled hot air at this stage – but I do intend to get to the bottom of this rumour; if true then someone better tell Boeing and a couple other not very well informed manufacturers.

Last edited by Kharon; 26th Jan 2013 at 22:49.
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Old 26th Jan 2013, 23:29
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C/S

I agree with you overall. While it is clear from the report that thrust was probably set. The fact is that neither pilot indicated they knew what thrust was set. The PF had no idea what was going on and the PNF (and training captain) called it as not being set. Smart move would be to pull it up from low speed. I don't agree with your go call at all "in this case".

There is lots not to like about this incident, most of which has been covered above. Another thing to look at is the role of the training captain. A simple advice to bring the lever back to the detent would have fixed this from the second the FMA came up . Thats what training people would normally do.........! There were passengers on this aircraft. The concept of lets see if he works it out is probably not a great one.
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Old 27th Jan 2013, 01:29
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Let me expand on the intent of my penultimate paragraph which i admit isn't clear, probably due to watching tv at the same time...

IF the thrust had been determined to be at least what was commanded then there is nothing inherently wrong with the GO command, particularly if the MAN THR was noticed over 100kts.

I still feel had the Airbus SOP calls been followed it is likely that this would never have happened.


Further criticisms of the nuances and actions (as to whether he should have left it or not) in the role of the Training Captain I'll leave to those of you more qualified than I.
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