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Qantas B744 stick shaker event near Hong Kong

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Qantas B744 stick shaker event near Hong Kong

Old 28th Mar 2019, 19:35
  #21 (permalink)  
 
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This event occurred due to poor airmanship and the recovery demonstrates this.
Didn't ANYBODY notice what the speed tape was doing?
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Old 28th Mar 2019, 21:43
  #22 (permalink)  
 
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Originally Posted by Dora-9 View Post
Didn't ANYBODY notice what the speed tape was doing?
Have a think about what happened and ask that question to yourself, and see if you can work out the answer. After you work that out, ask yourself why could this happen? Then you may end up with a lesson you can learn from .
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Old 28th Mar 2019, 22:10
  #23 (permalink)  
 
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Originally Posted by KABOY View Post
Acting at less than 'optimal performance' in a situation that is non normal due to poor pilot input I think sums this up. This event occurred due to poor airmanship and the recovery demonstrates this.

Placing an aircraft in an unstable state and recovering like this crew did raises multiple questions on automation management and disciplined recovery techniques. Aviate, navigate, communicate is still a valid concept on modern airliners.

Pilot training was Boeings first defence in the MAX accidents, Airbus was the same following Air France. Airbus thankfully only suffered one unreliable airspeed that led to deaths, a second would have seen the same outcome as Boeing. It was only through pilot training, experience and correct recovery that prevented a second significant loss of life.

I am sickened by the Qantas PR spin that the FO had their head looking out at other traffic in the holding pattern to ensure separation , shame I can't do that in IMC.

There is no sugar coating what is effectively a loos of control by three pilots on the flight deck. Three pilots having a bad day leads to a lot of questions, drawing WW1 parallels is a long bow.

well said - we could also add the human element of being punished, punitive actions and the consequences are forever in a pilots mind, I'd say this event shows exactly that by the way the Capt responded in his recovery actions by not wanting to go outside the Std Hldg pattern. Once an event happens like this there would be a high proportion of thought going into " oh sh1t we are in trouble now"!!
Humans only ever learn by their mistakes which we shall continue to do so for all time!
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Old 28th Mar 2019, 22:26
  #24 (permalink)  
 
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Originally Posted by KABOY View Post

I am sickened by the Qantas PR spin that the FO had their head looking out at other traffic in the holding pattern to ensure separation , shame I can't do that in IMC.
Thats a direct quote from the ATSB report. You haven't read it well have you?

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Old 28th Mar 2019, 22:54
  #25 (permalink)  
 
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see if you can work out the answer.
The answer I keep coming up with is one that doesn't reflect well on the crew. Not only do you have the "barber pole" segment on the speed tape rushing up towards your current IAS, but the appearance of the Pitch Limit Indicators would be yet another clue. To say that they were "too busy" to notice is simply breathtaking. What's more important?

it is even more rare to have such a large aircraft at so low a speed .
Really? I've been out of this world for over 10 years now, and even then higher altitude holding wasn't rare.
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Old 28th Mar 2019, 23:48
  #26 (permalink)  
 
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The incident was a perfect storm of an aircraft 1000 feet almost directly below them on entering the hold, a large angle of bank commanded by the FMC, an adverse wind change, which all happened at the same time, coupled with the speed requirement not being generally forthcoming.

That they were caught out is not surprising, however the aircraft below them, which was not in sight, was the real concern to the crew and lead to the stall recovery actions being incorrectly handled.

Once again with the "SkyGods" fellas??

Grow up.
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Old 29th Mar 2019, 01:49
  #27 (permalink)  
 
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Originally Posted by zanthrus View Post
Remember QF1? Captain allowed the crash. Captain is responsible for EVERYTHING that happens on his/her aircraft. QF should have written the hull off as uneconomical to repair but were so bloody minded about their reputation they spent more than a new aircraft to fix it. Shame Skygods Shame!This is the truth, QF and Little Gay Al will do anything to safeguard their reputation rather than admit fault.
Firstly, they did NOT spend more than a new airframe to fix it. Secondly, where do you think Qantas would have stood with every aviation hull insurer in the world if they'd knowingly put an aircraft back in the air that should have been written off... it doesn't take too much critical thinking to contradict that sort of uninformed bile being spewed in your comment. I happen to have worked with someone who was intimately involved with that incident and they are no lover of QF but have been adamant there is no way they could have gotten away with repairing the unrepairable.

I really wish idiots who have no idea what they are talking about would stop spreading this rubbish and that includes someone with an apparent axe to grind who repeated it in an otherwise lacklustre book... just stop it. Hate QF by all means if you wish but stop spreading BS.
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Old 29th Mar 2019, 01:57
  #28 (permalink)  
 
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Originally Posted by Capt Kremin View Post
The incident was a perfect storm of an aircraft 1000 feet almost directly below them on entering the hold, a large angle of bank commanded by the FMC, an adverse wind change, which all happened at the same time, coupled with the speed requirement not being generally forthcoming.

That they were caught out is not surprising, however the aircraft below them, which was not in sight, was the real concern to the crew and lead to the stall recovery actions being incorrectly handled.

Once again with the "SkyGods" fellas??

Grow up.
actually I find it very surprising that the crew were still reviewing charts and trying to visually identify an aircraft that was properly separated instead of monitoring the altitude capture and entry into the hold. I think the real reasons this crew got caught out have not been adequately explained in the investigation.
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Old 29th Mar 2019, 11:05
  #29 (permalink)  
 
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When I read an incident report like this, I try to imagine what the incident report could have looked like if the crew had reacted differently.

For example, when an incident report concludes that the pilot failed to follow the manufacturer’s published stick shaker response manoeuvre, the incident report omits the possibility that if the pilot had have followed the published manoeuvre, then it could have resulted in one of the world’s most tragic mid-air collisions.

Centaurus, you write a lot of good posts, and you are obviously a life-long student of aviation incidents and accidents, as we all should be. But please don’t be so dismissive of the “human factor” that is so prevalent as a contributing factor in many historical disasters. Yes, we should all know how to fly the fcking aircraft, but understanding our human limitations is crucial to continued safe flying. It’s not some dreamed-up lefty PC bullshit we use to excuse the Gen-Y’s. We used to say “toughen up princess”, but the planes kept crashing. We’re above that now, we’ve worked out that we’re humans. We can help prevent future disasters by studying and training the human element.

Although, according to a few other posters, it couldn’t possibly happen to them, because they are obviously aviation legends.

As for the “Sky God” comments from some, I work for Qantas. I consider myself very fortunate to do so. But not because Qantas made me a “Sky God”, in fact the opposite. Qantas taught me to be humble, recognise that my next flight could be my last, identify my weaknesses, learn from others, be conservative and safe, and never stop learning. They created a culture of self-reporting so that others can learn from my mistakes and I won’t be sacked unless I was reckless or rogue. They have a training/checking policy of training above checking, and the goal of a simulator session is to learn something rather than fear of failure. They don’t consider that to be perfect either, they constantly seek feedback on their training and checking, which they actually read. They certainly never taught me to think that I’m a better pilot than the next guy, but there seem to be a few others on this thread who think they are.

The reason bulk tax dollars are spent producing reports like this is so that we can all learn from them. I don’t see a lot of learning in this thread.

If I had a choice, I would prefer to fly with the crew from this incident over those legends on this thread who see fit to criticise their industry colleagues. Why do pilots do this? I’ve never witnessed a pilot gaining respect from their peers through self-promotion or deprecating others. (Edit: ok yeah there was this one QF guy who wrote a book, but most of us don’t drink with him).

Last edited by Derfred; 29th Mar 2019 at 12:31.
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Old 29th Mar 2019, 18:17
  #30 (permalink)  
 
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For example, when an incident report concludes that the pilot failed to follow the manufacturer’s published stick shaker response manoeuvre, the incident report omits the possibility that if the pilot had have followed the published manoeuvre, then it could have resulted in one of the world’s most tragic mid-air collisions.
Right, so he pitched down according to the report, but he failed to roll wings level. Last time I checked there was no holding pattern situated next to Betty, all traffic was holding in a vertical pattern(above and beneath). Maybe if he did roll wings level he would have removed the aircraft from a pattern where multiple aircraft were stacked. His actions in effect jeopardised the aircraft below him as he maintained the pattern laterally, but broke separation vertically.

Your sensationalist remark about avoiding a tragic mid air collision is sadly misguided and your defence of his actions only leads insult to your profession and that of Qantas's image.

I don’t see a lot of learning in this thread.
I have learnt quite a bit from this incident, aviate first, regardless of aircraft or airline. Did Qantas tell you that his actions actually avoided a mid air collision saving hundred of lives, or you make that up?

It seems the ATSB don't agree with that assertion, otherwise failing to comply with a manufacturer's course of action WOULD have been mentioned as a mitigating circumstance.
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Old 29th Mar 2019, 18:54
  #31 (permalink)  
 
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Is this the right room for an argument?
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Old 29th Mar 2019, 21:09
  #32 (permalink)  
 
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There’s plenty to learn from this incident report for all of us. I’m on the Bus with another carrier and this reminds me how capturing an altitude while commencing a holding pattern if the speed is left in managed mode could lead to precisely the same type of incident. If it’s not selected the speed drops to green dot while approaching the holding pattern and green dot is always the wrong speed at this time.
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Old 29th Mar 2019, 23:17
  #33 (permalink)  
 
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Originally Posted by KABOY View Post


Right, so he pitched down according to the report, but he failed to roll wings level. Last time I checked there was no holding pattern situated next to Betty, all traffic was holding in a vertical pattern(above and beneath). Maybe if he did roll wings level he would have removed the aircraft from a pattern where multiple aircraft were stacked. His actions in effect jeopardised the aircraft below him as he maintained the pattern laterally, but broke separation vertically.

Your sensationalist remark about avoiding a tragic mid air collision is sadly misguided and your defence of his actions only leads insult to your profession and that of Qantas's image.


I have learnt quite a bit from this incident, aviate first, regardless of aircraft or airline. Did Qantas tell you that his actions actually avoided a mid air collision saving hundred of lives, or you make that up?

It seems the ATSB don't agree with that assertion, otherwise failing to comply with a manufacturer's course of action WOULD have been mentioned as a mitigating circumstance.

again well said.

there will always be 'them & us'.
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Old 29th Mar 2019, 23:49
  #34 (permalink)  
 
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Originally Posted by KABOY View Post


Right, so he pitched down according to the report, but he failed to roll wings level. Last time I checked there was no holding pattern situated next to Betty, all traffic was holding in a vertical pattern(above and beneath). Maybe if he did roll wings level he would have removed the aircraft from a pattern where multiple aircraft were stacked. His actions in effect jeopardised the aircraft below him as he maintained the pattern laterally, but broke separation vertically.

Your sensationalist remark about avoiding a tragic mid air collision is sadly misguided and your defence of his actions only leads insult to your profession and that of Qantas's image.


I had the exact same thought on this rubbish protectionism of a fellow colleague.
When stalling in the hold, while in the turn, surely any 100hr+ pilot would come to the conclusion that straight ahead is the safest bet (to allow wings leveling and create space with traffic).

Maintaining the turn is nothing but 100% arse covering, and by far the most riskiest of the two options (both in not completing the stall recovery technique that Boeing and grade 3 instructors teach, and the loss of vertical separation).

If I was the crew simply going about their job safely below, having read this report, I’d be mighty miffed.








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Old 29th Mar 2019, 23:55
  #35 (permalink)  
 
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Originally Posted by machtuk View Post
….there will always be 'them & us'.
Sorry. Who's them and who's us?
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Old 30th Mar 2019, 00:50
  #36 (permalink)  
 
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Would they have hit the other aircraft? No idea. But the report indicated that the pilot’s recovery actions were influenced by his concern about traffic 1000’ below.

A few years ago we were subjected to a simulator exercise involving a stall recovery at low level during a turning RNP-AR approach. Rolling wings level in that scenario would have taken the aircraft towards terrain. The point of the exercise was that a “one-size-fits-all” stall recovery manoeuvre is not always the most appropriate course of action.

I’m not defending this crew’s actions, I’m just disappointed by the level of criticism by fellow colleagues.
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Old 30th Mar 2019, 02:34
  #37 (permalink)  
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the FDR readout is interesting, the deceleration rate was not rapid, nor was there a high sink rate for the step from F230 to F220. The automation was responding reasonably for the setup, just with a low target speed. The automatic entry from the angle of intercept will often result in bank angles above the normal value, to the 32 degree roll angle. (that angle can be exceeded, but it takes some effort from the crew to engibeer, and not in a good way). on level off, the pitch increase coincident with the bank angle and low speed starts the ball rolling.Aircraft get to this exact point every day around the world, the difference between a wild ride and routine ops being the initial speed.

In the level off and roll on hold entry, the speed tape min speeds would respond to the loading, but there is not much time available to intervene with something as simple as heading hold, thrust lever manual advancement.... to avoid the event. once it the event, the recovery procedure is in the QRH and FCTM. At high altitudes, excess thrust is limited, but at F220, MLW or below, there is copious thrust available.

Recovery involving a PIO is not surprising, during the event thrust changes are altering pitch moments and speed changes alter trim requirements, Unless hand flying of such cases are done in recurrent training, the PIO is not unexpected.

3 trained crew had a bad day, from an operator with a well established CRM/HF and cyclic training program, all speaking the same language... worthwhile lesson to them and any other operators of the potential to have a bad day.
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Old 30th Mar 2019, 07:23
  #38 (permalink)  
 
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I know that this is an open forum, but do we really need to put up with clowns nursing a grievance and who have never commanded anything bigger than a row boat?
Holding, especially at the end of a long flight, is a high threat environment.
One day, if I have the presence of mind, I’ll make a recording of an arrival into Sydney on a bad day. The number of heading instructions/speed changes/ holding entry altitude requirements/ departure from hold instructions then MORE heading instructions etc. etc. is beyond a joke. It would make an interesting Utube clip.
Only an idiot who has never been in that environment would ever think anything other than “ there but for the grace of God go I”
Incidentally, hardening up the speed in the FMC hold page is usually a defensive measure AGAINST get too slow. The FMC commands a minimum speed, not a practical speed. LNAV follows the path regardless of bank angle. Add an altitude change, distraction etc. and bingo! You’re on the front page.
Know-nothing trolls with a grievance against QF need to move on.
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Old 30th Mar 2019, 09:35
  #39 (permalink)  
 
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where do you think Qantas would have stood with every aviation hull insurer in the world if they'd knowingly put an aircraft back in the air that should have been written off.
Should have been written off economically, yes, but not due to the extent of the damage. QF wanted to avoid a hull loss so would have spent a heap of their own money to avoid that. Pretty much the same with a car that the insurers want to write off because it's uneconomic to repair but you can take their pay out, add some off your own moolah, and get it repaired.

Do you think they'd have put it back in the air if it wasn't insurable after the repairs? That it went back into the air means QF's standing with the aviation hull insurers was pretty good.
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Old 30th Mar 2019, 10:12
  #40 (permalink)  
 
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George Glass tells it how it is.
At the end of a long day none of us are at our best.
The ATSB report states that fatigue was not considered a factor. But does not provide a summary of how many days worked in last month, duty hours in last week, preceding rest, time of sign on etc.
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