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Final Report on B737 severe upset and Loss of control by F/O

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Final Report on B737 severe upset and Loss of control by F/O

Old 9th Oct 2014, 01:40
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Final Report on B737 severe upset and Loss of control by F/O

http://www.mlit.go.jp/jtsb/eng-air_report/JA16AN.pdf

Above is the link to the Final report on an All Nippon B737-700 JA16AN nosedive from Upset at 41,000 ft on 6 September 2011. Nightime.

The 100-page document also highlights the 38-year-old co-pilot's delayed and confused response, which investigators attributed to gaps in training, undue reliance on automation and seeming anxiety about quickly letting the captain back into the cockpit. According to the report, "excessive dependence on autopilot" exacerbated "lack of full awareness about the need to monitor" flight controls. The co-pilot couldn't recall the stick shaker's activation, it said.

The report said the co-pilot failed to recognize there was a problem for 17 seconds, and then alternately pushed forward and pulled back on the controls. The captain, returning from a bathroom break, was locked out of the cockpit while the plane nose-dived and executed back-to-back rolls in opposite directions. The maneuvers lasted about 90 seconds, though passengers may not have fully realized what was happening because it was dark outside.

With the large number of the Boeing 737 Series operating in Australia, pilots should find time to read this lengthy report. The captain had left the cockpit for a toilet visit leaving the F/O alone up front. He had never been alone up front before, which considering what happened next is probably understandable. To put it bluntly he didn't have a clue. Yet he was certified as competent to be second in command. The starting point for the gyrations of the 737 through the F/O's attempts at recovery was he inadvertently actuated the rudder trim instead of the cockpit door unlocking switch. Angles of bank reached 130 degrees which is close to inverted. This was at night initially on autopilot until the autopilot gave up the ghost and said "All yours" Included in the report was comment that the operator did not include simulator training for high altitude unusual attitudes and stall recovery. Many operators don't either, considering it unnecessary.

Last edited by Centaurus; 9th Oct 2014 at 01:58.
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Old 9th Oct 2014, 02:00
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I had an FO recently who said "but you'd never find yourself there, would you?" as we were dicussing extreme UAs. The point is, you just never know when, how or why...
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Old 9th Oct 2014, 02:37
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Angles of bank reached 130 degrees which is close to inverted.

He had never been alone up front before,


How do we find out if someone has no idea until it hits the fan?
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Old 9th Oct 2014, 03:28
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How do we find out if someone has no idea until it hits the fan?
The Check & Training system is supposed to be the filter to weed these problems out. They should never get cleared to line at that level of competence. If they manage to slip through that filter, the on going recurrent training should have exposed the problem. Then it should be either adequate re-training or, if they are unable to reach a satisfactory standard after a suitable period of re-training, the unfortunate situation of letting them go.

Unfortunately the check & training departments of many airlines have been watered down so much that this is what we can now expect into the future. The 'PC' brigade, the 'unfair dismissal' brigade & the 'near enough is good enough' brigade all have to share some of the responsibility. Airline flying is a serious business with serious consequences if you get it wrong, which is true to some extent of all forms of aviation. However, some seem to feel that this is not the case & we can all be a little casual in our approach to it. The old term 'Aero Club with jets' springs to mind.
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Old 9th Oct 2014, 04:23
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How do we find out if someone has no idea until it hits the fan?
Is that a serious question? Really?

You train and check for these things in a simulator. Simple. We do UA's EVERY sim and the IRT REQUIRES them to be done each year.
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Old 9th Oct 2014, 04:48
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I'm surprised pilots in Asia don't stack their planes more often.
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Old 9th Oct 2014, 06:50
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Icarus, of course it was a serious question.

Despite what you say there was some guy up front that had serious issues controlling his aircraft.

There are some seriously flawed checks being carried out if this guy is deemed competent.
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Old 9th Oct 2014, 07:52
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There are some seriously flawed checks being carried out if this guy is deemed competent.
Using that logic, you could say the same about JQ after someone ended up in alpha floor trying to conduct a simple change of level.
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Old 9th Oct 2014, 08:34
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you sure could.

how many alpha floors have jq had now? 3?
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Old 9th Oct 2014, 10:53
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The report states that during UA "training" in the simulator the pilots being trained were told to close their eyes while the instructor or testing officer put the aircraft into a UA. What is the purpose of that? Pilots undergoing initial instrument flying training in (say) Cessna 172 wear an IFR hood so that in theory they cannot sneak a look outside to see the horizon. In addition the instructor gets them to look down and close their eyes for the same reason - to prevent cheating.
But in a simulator where IMC is programmed, the candidate cannot cheat by looking outside. So why is it that some simulator instructors still tell pilots to close their eyes and look down while the instructor flings the simulator around and says "Handing Over, Bloggs - sort out that lot"
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Old 9th Oct 2014, 13:34
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Originally Posted by Tee Emm
But in a simulator where IMC is programmed, the candidate cannot cheat by looking outside. So why is it that some simulator instructors still tell pilots to close their eyes and look down while the instructor flings the simulator around and says "Handing Over, Bloggs - sort out that lot"
To test that the pilot can actually work out what the current situation is then recover. If he can't, then he needs more training.

There may not be an outside horizon, but watching the ADI as the simmo puts you in a UA is effectively the same and makes the whole exercise a waste of time.

Last edited by Capn Bloggs; 10th Oct 2014 at 05:23.
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Old 9th Oct 2014, 14:10
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High altitude, and more importantly, high mach number, upsets are more critical that the low altitude stuff that you see first as a trainee pilot, and later reinforced in stall training.

Angle of attack is critical at the margins of the envelope, but there seems to be a cognitive gap in the average line pilot's appreciation of the values involved. On my own type there has been a well documented fatal stall "accident", yet no line pilot I have conversed with could guess the stall alpha at FL370, Mach 0.82. (It is 4, by the way, a number that I could scarcely credit when I first heard it.)

Basic understanding of low and high speed buffet, mach effects and other high speed aerodynamics seem to have fallen out of favour, replaced by the false promise of centre-of-the-envelope optimism. You should always aim for the centre, but train for the region outside of the limits.

Many modern aircraft have a device that displays actual aircraft path relative to the longitudinal and horizontal axes of the aircraft. It is called by different names,(FPV, Bird) but it does display the horizontal drift and the gamma. If you know gamma and theta, you can instantly detect alpha, unless of course you allow gamma to get off the scale, as happened in AF447.

My user name pretty much shouts "dinosaur", but at least we dinosaurs knew that we were in need of help, so we poured over "Handling the Big Jets", "Fly the Wing" and "Aerodynamics for Naval Aviators" to name but three classics.

Finally: the 737 rudder trim knob has caused a crash before this attempt. It is not impossible to grasp it by mistake when groping for the cockpit door switch. The tactile clues inherent in slightly different knobs are obviously insufficient for all users. Time for a relocation of the door lock switch to a position not adjacent to the rudder trim.
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Old 9th Oct 2014, 19:17
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"you sure could.

how many alpha floors have jq had now? 3?"






How many times have JQ put an aircraft into a golf course???
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Old 9th Oct 2014, 19:34
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Originally Posted by Australopithecus View Post

Finally: the 737 rudder trim knob has caused a crash before this attempt. It is not impossible to grasp it by mistake when groping for the cockpit door switch. The tactile clues inherent in slightly different knobs are obviously insufficient for all users. Time for a relocation of the door lock switch to a position not adjacent to the rudder trim.
No! Look at the ing thing before you turn it.
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Old 9th Oct 2014, 21:44
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Lord Spandex Masher. Generally that's a useful idea, the looking at things. But not all stressed people perform all the usual steps, as in this case. A very good design would eliminate such areas of tactile ambiguity.

The pilot seat occupier in this case needed quick assistance, not quick and unexpected yaw. I'll bet he didn't have an extra three seconds to look for the knob given the gyrations of the aeroplane.
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Old 9th Oct 2014, 22:46
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Apart from better high altitude training, one thing that has always puzzled me, is why no angle of attack indicator? I must admit a 4 degree critical alpha is a surprise but so was the height loss in a stalling session just completed in a sim renewal. More education in this area seems to be happening at last, but its been a long time coming.
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Old 9th Oct 2014, 23:00
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The pilot seat occupier in this case needed quick assistance, not quick and unexpected yaw. I'll bet he didn't have an extra three seconds to look for the knob given the gyrations of the aeroplane.
It was the activation of the wrong switch that caused the 'gyrations'. He shouldn't have been that stressed sitting there monitoring the aircraft that he couldn't look at the switch before activating it. If he was, he should not have been on the flight deck in the first place.
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Old 10th Oct 2014, 00:07
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Yes, I know. But how many times, honestly, have you seen dumb things done on a flight deck out of well-intentioned but flawed actions?

I have had 737 pilots turn off the B hydraulics instead of engine anti-ice, I have had them do the rudder trim trick, I have had them start to retract the flaps instead of the gear. (Exciting! Fun for all ages!) I am sure that I have pulled some bone-headed maneouvers of my own too.

The Helios Airlines 737 pressurisation crash was due to the commonality of the cabin pressure and take-off warning horn.

My point in all of this is that good cockpit ergonomic design tries to eliminate ambiguity. Thats why gear levers became wheel shaped and flap handles look like airfoils. You can be a he-man aviator all you want. I was that way too, once. Flight Directors? Autopilots? Pffft Kid Stuff! Eventually it sunk into my thick, primitive skull that I was fallible, as are the guys with whom I fly. Hence my comments about the switch design.

Last edited by Australopithecus; 10th Oct 2014 at 00:29. Reason: On edit: Oakape pointed out my error regarding Helios which I then corrected.
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Old 10th Oct 2014, 00:24
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Yeah mate, we have all seen dumb things done on the flight deck. The smart ones learn from it & pass the lesson on to others in an attempt to avoid a repeat. The dumb ones wonder what the hell happened.

The 737 accident you are referring to is the Helios one, not Turkish Airlines.

And if you take a look at the photos in the report you will see that there was significant tactile difference between the two switches in question. Similar to the difference between the flap & gear handles. It would seem however, that there are differences in how various airlines position theses panels in the pedestal. Perhaps there is room for improvement there.

Accuracy is important in this business, hence the comments in my other post.
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Old 10th Oct 2014, 04:20
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It's safer to take some FO's to the bathroom with you....
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