B777 Emergency DXB

[AfricanSkies]

Palm TOGA buttons work quite well, mainly because the thrust levers have to be open before you can access them.

Perhaps these Boeing TOGA buttons should only be pressed after the thrust levers have been opened and the FCOM which reads 'A missed approach is accomplished by selection of either TOGA switch' should include some mention of advancing the thrust levers and the FTCM should perhaps read 'advance thrust levers, push either TOGA switch... ' instead of simply the 'Push either TOGA switch, call for flaps 20, ensure go-around thrust for the nominal climb rate is set and monitor autopilot performance'.

The almost total reliance on automation is quite clear.

If this incident had been a go-around at low level with a TOGA button failure (ie. Not a balked landing after a touchdown), the results would probably have been very similar.

[CaptainChipotle]

Originally Posted by AfricanSkies

Palm TOGA buttons work quite well, mainly because the thrust levers have to be open before you can access them.

Perhaps these Boeing TOGA buttons should only be pressed after the thrust levers have been opened and the FCOM which reads 'A missed approach is accomplished by selection of either TOGA switch' should include some mention of advancing the thrust levers and the FTCM should perhaps read 'advance thrust levers, push either TOGA switch... ' instead of simply the 'Push either TOGA switch, call for flaps 20, ensure go-around thrust for the nominal climb rate is set and monitor autopilot performance'.

The almost total reliance on automation is quite clear.

If this incident had been a go-around at low level with a TOGA button failure (ie. Not a balked landing after a touchdown), the results would probably have been very similar.

The manual states "Ensure Go-Around thrust is set"

Keep it simple, stupid.

CC

[The Outlaw]

CC,

You are correct to a point. However, perhaps physically moving the thrust levers to the GA thrust position and keeping your hand on them (like is done in the A80, DC-8, L1011, C-172, ATR42, Dash-8, RJ, etc, etc.) much like any aircraft ever built is a pretty solid guarantee that the thrust will increase to GA thrust unless of course you suffered the same fate as the BA 777 crew in LHR.

"Ensure GA thrust is set" can mean many things. Did you set CLIMB thrust? Did you set MCT thrust? Did you set something in between? Is one lever in GA and the other in MCT? In the midst of the Go Around, the PF will be pretty focused on the ADI and airspeed. That statement is just a confirmation point that "GO AROUND" thrust was set. I would assume that the 777 must have some sort of indication on the "FMA" or auto thrust indication that would confirm same? Also, the confirmation of "GA THRUST SET" would be the duty of the PM (PNF), so if it isn't set then does he prompt the PF to set it? Does he do it himself? Is it normal in the Boeing for a PM to manipulate the thrust levers at any time? Or does he just take control outright? What are the protocols in this regard? Does it make sense to not advance the thrust levers by hand and put all the reliance on the automation to do it for you? There are many incidents and accidents out there that prove over reliance on automation AND loss of handling skills are becoming the main cause of hull losses.
Years ago when I flew jurassic jets, one moved the thrust levers to MAX EPR for GA. Of course you'd never perfectly peg the required EPR setting so the PM (PNF) would fine tune the EPR. Perhaps this is the base for the statement?

The old adage of automation still stands. "If its not doing what you asked for, then do it yourself."

The Outlaw.

[CaptainChipotle]

Originally Posted by The Outlaw

CC,

You are correct to a point. However, perhaps...

I quoted the manual. Airmanship dictates that you physically make sure the throttles are moving, and that thrust is increasing.

Boeing is ambiguous for a reason. I'm too lazy to write it out, but I'm sure you know why.

But I agree with you, if you don't like what it's doing, do it yourself! Sadly, I think that skill is slowly falling off.

CC

[Monarch Man]

"Ensure GA thrust is set" can mean many things. Did you set CLIMB thrust? Did you set MCT thrust? Did you set something in between? Is one lever in GA and the other in MCT? In the midst of the Go Around, the PF will be pretty focused on the ADI and airspeed. That statement is just a confirmation point that "GO AROUND" thrust was set. I would assume that the 777 must have some sort of indication on the "FMA" or auto thrust indication that would confirm same? Also, the confirmation of "GA THRUST SET" would be the duty of the PM (PNF), so if it isn't set then does he prompt the PF to set it? Does he do it himself? Is it normal in the Boeing for a PM to manipulate the thrust levers at any time? Or does he just take control outright? What are the protocols in this regard? Does it make sense to not advance the thrust levers by hand and put all the reliance on the automation to do it for you? There are many incidents and accidents out there that prove over reliance on automation AND loss of handling skills are becoming the main cause of hull losses.
Years ago when I flew jurassic jets, one moved the thrust levers to MAX EPR for GA. Of course you'd never perfectly peg the required EPR setting so the PM (PNF) would fine tune the EPR. Perhaps this is the base for the statement?

The old adage of automation still stands. "If its not doing what you asked for, then do it yourself."

The Outlaw.

Outlaw, therein lies the rub, procedurally the FCOM has been written by lawyers to mitigate liability, its then applied as a "one size fits all" Boeing procedure that is "trained" and "enforced" by the various competing egos within the company such that we arrive at a point where airmanship and resilience are replaced with compliance and dependency.
All of this has predictably led us to when something unexpected or unplanned for happened, it was beyond the capability of the crew to recognise and recover.
I will keep saying this until I'm blue in the face, a simple push and hold of the thrust levers would have avoided this particular outcome....taking it a step back to 1000ft or so AGL on approach, disconnecting the AT and being in charge and aware of the thrust setting would have in my view broken one of the links in the error chain (from a motor skills viewpoint) of the incident such as it was.
I am and continue to be completely against the use of auto thrust for a manual landings as it in my view at least removes a key element of situational awareness.... we fly the 777 like an Airbus, its not the quiet dark cockpit concept at all, there are more calls than are Bangalore call centre.

[777-200LR]

if you don't like what it's doing, do it yourself! Sadly, I think that skill is slowly falling off.

While I agree to an extent with this statement, I also equally disagree. An airplane seldom (not never) does "what it's doing", thats a result of lost of SA or more likely lack of aircraft knowledge. The common recent examples were the famous "after DESDI, left turn heading 290, and when heading was engaged, the aircraft would begin turning right. Would that be the best time to disconnect the AP and turn the aircraft yourself? The 'pre-set' heading was not an SOP for a reason due to the aircraft's design to turn the shortest way.

[anson harris]

Would that be the best time to disconnect the AP and turn the aircraft yourself?

I would argue that that would be the best time to press Hdg Hold. As lots of people seem to lose the plot when the autpilot is unexpectedly disconnected, the safest option would seem to be to reduce the level of automation to the most basic. If that doesn't work, then disconnect. Understanding the automation options that are available to you when things are not going to plan is just as important as being able to fly the thing. Possibly more so these days.

[glofish]

Monarch Man said:

I will keep saying this until I'm blue in the face, a simple push and hold of the thrust levers would have avoided this particular outcome

The Outlaw said:

Years ago when I flew jurassic jets, one moved the thrust levers to MAX EPR for GA

I couldn’t agree more. Before the age of Nintendoes, the GA for the PM was a matter of: “Did the buddy hit the GA EPR/N1 limit correctly? Or do i have to adjust a slight over/underthrust?”. The power was always on though, there has not been one documented GA incident where the PF did not shove up the non automated levers.
Today his problem is: “Did the the buddy hit the button/position? Did he hit the right button/position? And did the Nintendo effectively obey the desired command?”. The power might not be on! -> we just invented a new threat! QED.
I leave it to everyone to judge which solution is easier and therefore safer …..

[777-200LR]

I would argue that that would be the best time to press Hdg Hold.

That's exactly the point I was trying to make. The reason many would disconnect the AP immediately, is for that very reason; not knowing the quick options available while still keeping a level of automation. Here's another example, how many times have you seen guys push ALT intervention to cancel a speed restriction?

[linedriva]

777-200LR Quote .....'Here's another example, how many times have you seen guys push ALT intervention to cancel a speed restriction?'

That's one of my pet hates too - some seem to be unaware of what they're actually doing. And it's not only FO's that do it either.

[lospilotos]

Clue is on the name, "ALT intervention", it removes the altitude constraint. As a consequence the speed also gets removed as you cannot have a speed constraint without an altitude constraint on the same line... I use SPD intervention, or if workload permits and it's appropriate, modify the FMC accordingly.

[fatbus]

Does anyone remember AA 757 Cali , Boeing refused to change the auto speed brake retraction with TOGA. It would admit a fault in the design. Same applies. FCOM is by the letter of the law correct. If the speed brakes were retracted that 757 would not have had a CFIT.

[Lynx8]

For sure the guys did not crash the aircraft on purpose. We can all agree on this right?
Usually, in Human Factors related issues, the brain plays a tricky role mainly due to 3 reasons:
A) Visual illusions;
B) CFIT;
C) Automated mind reaction to a situation similar to another situation.

In the EK521 case A and B are excluded and hope we all agree on this.
Case C has played a big role IMHO regardless what really happened, regardless all the possible missing pilots interventions and regardless Boeing and EK documentations.

When we take off, we are obviously on the ground, and upon approaching to the lift off stage we have already taken hand off the Thrust Levers.
It is an automated mind reaction that we do on every flight. V1…hand off Thrust Levers…VR and lift off.
Next flight….. V1…hand off Thrust Levers…VR and lift off.
Next flight again...V1…hand off Thrust Levers…VR and lift off.
We have all done this for weeks, months and years in our aviation careers right?

In the EK521 case we can assume a solid possibility that, once on the ground and due to an imminent aircraft lift off, upon calling go-around, pressing TOGA bla bla bla, the “automated mind reaction” has played its role simply telling the arm to be removed from the Thrust Levers and to be placed on the control wheel.
Obviously there is not a justification and no one is trying to find excuses, but in 30+ years of flying experience, 20+ years in Flight safety and 12+ years as Cpt 777 experience and Training got some feeling that we are not too far from an additional Human Factor piece of the puzzle.
My humble suggestion during training and non-training flights has always been “If we Go-around at any stage make sure, whoever is PF, that his/her arm is on Thrust Levers and his/her arm is at 180 degrees angle fully extended. If PF's arm on Thrust Levers is not full extended until missed approach altitude is reached something might go terribly wrong.”
Last, but not least, in this occasion having trust at idle let the aircraft stall and stop near threshold 30R.
If it was set set only 50%-60% and left it there, for any other reasons, the aircraft would have stalled at a later stage probably into Mirdif....and let's stop it here.

[Talparc]

https://www.usnews.com/news/world/ar...-faults-report



This accident is also based on the threatening company culture.

But nobody wants to admit same for the time being.

[JammedStab]

Originally Posted by lospilotos

Clue is on the name, "ALT intervention", it removes the altitude constraint. As a consequence the speed also gets removed as you cannot have a speed constraint without an altitude constraint on the same line...

Never actually tried that before. If the altitude is just an intentionally out of the way altitude entered in order to be able to get the speed entered as a restriction, wouldn't deleting that contstraint just change the commanded speed back to whatever is in VNAV? Might work.

[ironbutt57]

one good feature I suppose in the Airbus is a Go-around is commenced by actually moving the thrust levers forward...not to say it's necessarily better, but more intuitive maybe

[lospilotos]

Originally Posted by JammedStab

Never actually tried that before. If the altitude is just an intentionally out of the way altitude entered in order to be able to get the speed entered as a restriction, wouldn't deleting that contstraint just change the commanded speed back to whatever is in VNAV? Might work.

Of course it works but you might unintentionally be removing an altitude constraint that is actually a valid one not just one put in to allow for speed entry.

[Jack330]

*

Man, sorry to contradict you but 737 and 777 fly exactly the same way with the latest being much easier to handle.. That's my point as I fly the 777 now and I flew the 737NG for years.

[Talparc]

Emirates accident investigators study human performance, weather notification | Safety content from ATWOnline

[CaptainChipotle]

Originally Posted by Jack330

Man, sorry to contradict you but 737 and 777 fly exactly the same way with the latest being much easier to handle.. That's my point as I fly the 777 now and I flew the 737NG for years.

Almost spit out my beer with this one. Lack of sleep and chronic fatigue must have kicked in Jack. And yesssss, I've flown both.