B737-400 overseas incident worth study by all pilots
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B737-400 overseas incident worth study by all pilots
The Royal Air Maroc Boeing 737-400 CN-RMF with 156 passengers, 4 Royal Air Maroc cabin crew and 2 Atlas Blue pilots, the captain (36, ATPL, 7,540 hours total, 7,200 hours on type) being pilot flying and the first officer (28, ATPL, 2,730 hours total, 2,308 hours on type) being pilot monitoring, departed Schiphol Airport's runway 18L, flaps were set at 5 degrees, engines stabilized at 93.8 and 94.0% N1.
The aircraft accelerated through 171 KIAS during rotation (nose up attitude of 6 degrees) and became airborne, at 16 feet AGL the gear was selected up at a speed of 175 KIAS. At that moment the aircraft collided with a flock of geese, which resulted in an immediate loss of all thrust from the left hand engine, the nose landing gear indicated unsafe because of the position of the nose gear did not agree with the selected position. 6 seconds later the aircraft climbed through 140 feet at engine thrust of 45.5% N1 and 93.8% N1, the left engine remained at 45% N1 for the next 4 minutes until shut down. The first officer called out engine #1 was damaged, the call was not responded to by the captain however. The captain remarked that the aircraft was shaking violently and was difficult to control.
By himself, without sharing his thoughts with the first officer, he wondered whether both engines had been damaged so that insufficient thrust remained available to sustain flight, therefore he wanted to return immediately considering the decision to return was obvious. He instructed the first officer to select the landing gear down again and declare Mayday, the first officer selected the landing gear down without discussion, then declared emergency.
At a height of 280 feet the commander initiated a right hand turn. Despite the gear being selected down the nose gear continued to indicate unsafe. By the time the first officer completed the Mayday call the aircraft had already reached a bank angle of 21 degrees, the controller recognizing the right turn instructed the aircraft to roll out at 330 degrees and expect vectors for runway 18R. The aircraft reached a maximum bank angle of 37.5 degrees (according to flight data recorder) at an airspeed that reduced from 179 to 156 KIAS. The right hand engine's thrust lever was manually reduced to 83% N1 despite autothrottle being engaged, autothrottle was subsequently disengaged.
The aircraft continued to climb slowly reaching 498 feet AGL before descending again at low rate, the GPWS sounded "Don't sink! Don't sink!", the airspeed continued to decrease through 145 KIAS. 60 seconds after initiating the turn the aircraft finally rolled wings level at a heading of 344 degrees.
The captain then requested the first officer to repeat the instructions received from air traffic control and noticed that the nose gear indicated unsafe, the discussion however got interrupted by the purser who called the cockpit reporting the left hand engine was on fire. The captain ignored that message and instead instructed the first officer to tell the cabin crew they were returning to Schiphol. During the next 23 seconds the air traffic controller inquired with the first officer whether the aircraft was able to maintain altitude and whether they could accept vectors, the captain talked to the purser who repeated the left engine was on fire, the GPWS activated a number of times prompting the right thrust lever to be pushed forward until the engine reached 101% N1 and the aircraft began to climb again.
After the first officer had finished the transmissions with ATC the captain requested the information to be repeated. The aircraft reached 352 feet and began to descend again, the GPWS again activated "Don't sink!" and "Too Low, Terrain!".
The purser entered the cockpit, the first officer asked him to verify through the peep hole whether the nose gear was extended, then responded to a radio transmission by ATC, which transferred the aircraft onto a discrete frequency (a frequency with no other aircraft on). The purser confirmed the nose gear was down and locked.
The captain increased the right hand thrust lever further to just below firewall, the aircraft began to climb again, the GPWS alerts ceased but nose landing gear warnings now sounded. While the two pilots discussed the new warning ATC issued a heading of 350 degrees to join the downwind for runway 18R and asked whether the aircraft was able to climb, which the crew replied in the negative to
.
The gear warning ceased when the aircraft overflew the villages of Vijfhuizen and Haarlem at heights of 380 to 500 feet. When the aircraft was north of these villages ATC issued a new heading of 100 degrees and advised they were 4 miles from touchdown. The captain initiated the turn but rolled out at 065 degrees, the left hand engine was shut down following the memory checklist "Engine Fire or severe damage or separation", while the memory checklist was executed ATC issued heading 160, the instruction was not responded to and was not followed. ATC issued a heading of 210 degrees, the instruction was again not followed, only a minor right turn followed. By that time the crew had completed the memory checklist and found the aircraft north of the aerodrome passing through the extended centerline of runway 18L. ATC issued a heading of 270 to return the aircraft to runway 18R, the crew completed the rest of the checklists concerning the left engine and completed programming of the flight management computer, the aircraft turned through 110 degrees, the first officer inquired with ATC for vectors and was again instructed to turn onto a heading of 270.
The crew inquired whether a landing on runway 18L was possible, the approach controller declined because of obstacle clearance (Sony Building) just north of runway 18L. The crew discussed the aircraft was difficult to control, although the engine thrust was constant the airspeed was fluctuating between 160 and 170 knots, the first officer called speed when the airspeed decrased to 156 KIAS. The captain attempted to adjust the right hand thrust lever but noticed it was already at maximum thrust and instructed to firewall the engine for 5 seconds (103.9% N1).
The crew, seeing runway 18C, inquired whether a landing on 18C was possible, which was approved, however, the crew reconsidered and decided to go ahead with the original plan to land on runway 18R, the aircraft was heading at 310 degrees. ATC issued a heading to 215 degrees, the first officer called the instruction out aloud and assisted the captain performing the turn with verbal callouts. The captain captured the localizer manually and flew the ILS with flaps still at 5 degrees.
On final approach the captain instructed the first officer to advise cabin crew to not evacuate but prepare for a hard landing. The first officer did not pass that message because the aircraft was already on short final and the first officer called out speeds and sinkrates in order to assist the captain. After main wheel touch down at 175 KIAS the first officer announced the automatic wheel brakes did not engage, the captain instructed to turn the system off, the first officer suggested to keep those nose up as long as possible, followed by a safe touchdown of the nose gear. While the aircraft rolled out the captain again instructed that no evacuation would be done unless there was fire. The aircraft came to a stop on the runway, the right hand engine was shut down.
Emergency services reported no smoke or fire. The right main gear tyres deflated. The passenger disembarked via mobile stairs.
The remains of 24 geese were found in the left main landing gear, the nose landing gear and the electronic compartment.
Examination of the aircraft revealed:
- dents in the underside of the fuselage near the nose of the aircraft
- a dent in the leading edge of the vertical fin
- dents and cracks at the leading edge of the left hand engine's inlet and dents inside the engine
- three fanblades fractured at about midspan damaging all the rest of the fan blades
- the left engine's low and high pressure compressor, the combustion chamber, high pressure turbine guide vanes, high pressure turbine blades, low pressure turbine outlet guide vanes, and first to fourth low pressure turbine stages were all damaged
- on the left side of the left hand engine was soot and oil
- on the fuselage were traces of oil
- the right main gear brakes were jammed
Pollution with engine oil was reported from the village of Harleem, the investigation however could not establish the source of the oil spill stating that the aircraft did not overfly the specific area in question.
Immediately after departure of the Boeing Schiphol operations were advised of a possible bird strike on runway 18L and recovered the remains of 7 dead Canada Geese, weights between 3 and 5 kg (6.6 to 11 lbs) from runway 18L around about the extended centerline of runway 06/24.
The aircraft accelerated through 171 KIAS during rotation (nose up attitude of 6 degrees) and became airborne, at 16 feet AGL the gear was selected up at a speed of 175 KIAS. At that moment the aircraft collided with a flock of geese, which resulted in an immediate loss of all thrust from the left hand engine, the nose landing gear indicated unsafe because of the position of the nose gear did not agree with the selected position. 6 seconds later the aircraft climbed through 140 feet at engine thrust of 45.5% N1 and 93.8% N1, the left engine remained at 45% N1 for the next 4 minutes until shut down. The first officer called out engine #1 was damaged, the call was not responded to by the captain however. The captain remarked that the aircraft was shaking violently and was difficult to control.
By himself, without sharing his thoughts with the first officer, he wondered whether both engines had been damaged so that insufficient thrust remained available to sustain flight, therefore he wanted to return immediately considering the decision to return was obvious. He instructed the first officer to select the landing gear down again and declare Mayday, the first officer selected the landing gear down without discussion, then declared emergency.
At a height of 280 feet the commander initiated a right hand turn. Despite the gear being selected down the nose gear continued to indicate unsafe. By the time the first officer completed the Mayday call the aircraft had already reached a bank angle of 21 degrees, the controller recognizing the right turn instructed the aircraft to roll out at 330 degrees and expect vectors for runway 18R. The aircraft reached a maximum bank angle of 37.5 degrees (according to flight data recorder) at an airspeed that reduced from 179 to 156 KIAS. The right hand engine's thrust lever was manually reduced to 83% N1 despite autothrottle being engaged, autothrottle was subsequently disengaged.
The aircraft continued to climb slowly reaching 498 feet AGL before descending again at low rate, the GPWS sounded "Don't sink! Don't sink!", the airspeed continued to decrease through 145 KIAS. 60 seconds after initiating the turn the aircraft finally rolled wings level at a heading of 344 degrees.
The captain then requested the first officer to repeat the instructions received from air traffic control and noticed that the nose gear indicated unsafe, the discussion however got interrupted by the purser who called the cockpit reporting the left hand engine was on fire. The captain ignored that message and instead instructed the first officer to tell the cabin crew they were returning to Schiphol. During the next 23 seconds the air traffic controller inquired with the first officer whether the aircraft was able to maintain altitude and whether they could accept vectors, the captain talked to the purser who repeated the left engine was on fire, the GPWS activated a number of times prompting the right thrust lever to be pushed forward until the engine reached 101% N1 and the aircraft began to climb again.
After the first officer had finished the transmissions with ATC the captain requested the information to be repeated. The aircraft reached 352 feet and began to descend again, the GPWS again activated "Don't sink!" and "Too Low, Terrain!".
The purser entered the cockpit, the first officer asked him to verify through the peep hole whether the nose gear was extended, then responded to a radio transmission by ATC, which transferred the aircraft onto a discrete frequency (a frequency with no other aircraft on). The purser confirmed the nose gear was down and locked.
The captain increased the right hand thrust lever further to just below firewall, the aircraft began to climb again, the GPWS alerts ceased but nose landing gear warnings now sounded. While the two pilots discussed the new warning ATC issued a heading of 350 degrees to join the downwind for runway 18R and asked whether the aircraft was able to climb, which the crew replied in the negative to
.
The gear warning ceased when the aircraft overflew the villages of Vijfhuizen and Haarlem at heights of 380 to 500 feet. When the aircraft was north of these villages ATC issued a new heading of 100 degrees and advised they were 4 miles from touchdown. The captain initiated the turn but rolled out at 065 degrees, the left hand engine was shut down following the memory checklist "Engine Fire or severe damage or separation", while the memory checklist was executed ATC issued heading 160, the instruction was not responded to and was not followed. ATC issued a heading of 210 degrees, the instruction was again not followed, only a minor right turn followed. By that time the crew had completed the memory checklist and found the aircraft north of the aerodrome passing through the extended centerline of runway 18L. ATC issued a heading of 270 to return the aircraft to runway 18R, the crew completed the rest of the checklists concerning the left engine and completed programming of the flight management computer, the aircraft turned through 110 degrees, the first officer inquired with ATC for vectors and was again instructed to turn onto a heading of 270.
The crew inquired whether a landing on runway 18L was possible, the approach controller declined because of obstacle clearance (Sony Building) just north of runway 18L. The crew discussed the aircraft was difficult to control, although the engine thrust was constant the airspeed was fluctuating between 160 and 170 knots, the first officer called speed when the airspeed decrased to 156 KIAS. The captain attempted to adjust the right hand thrust lever but noticed it was already at maximum thrust and instructed to firewall the engine for 5 seconds (103.9% N1).
The crew, seeing runway 18C, inquired whether a landing on 18C was possible, which was approved, however, the crew reconsidered and decided to go ahead with the original plan to land on runway 18R, the aircraft was heading at 310 degrees. ATC issued a heading to 215 degrees, the first officer called the instruction out aloud and assisted the captain performing the turn with verbal callouts. The captain captured the localizer manually and flew the ILS with flaps still at 5 degrees.
On final approach the captain instructed the first officer to advise cabin crew to not evacuate but prepare for a hard landing. The first officer did not pass that message because the aircraft was already on short final and the first officer called out speeds and sinkrates in order to assist the captain. After main wheel touch down at 175 KIAS the first officer announced the automatic wheel brakes did not engage, the captain instructed to turn the system off, the first officer suggested to keep those nose up as long as possible, followed by a safe touchdown of the nose gear. While the aircraft rolled out the captain again instructed that no evacuation would be done unless there was fire. The aircraft came to a stop on the runway, the right hand engine was shut down.
Emergency services reported no smoke or fire. The right main gear tyres deflated. The passenger disembarked via mobile stairs.
The remains of 24 geese were found in the left main landing gear, the nose landing gear and the electronic compartment.
Examination of the aircraft revealed:
- dents in the underside of the fuselage near the nose of the aircraft
- a dent in the leading edge of the vertical fin
- dents and cracks at the leading edge of the left hand engine's inlet and dents inside the engine
- three fanblades fractured at about midspan damaging all the rest of the fan blades
- the left engine's low and high pressure compressor, the combustion chamber, high pressure turbine guide vanes, high pressure turbine blades, low pressure turbine outlet guide vanes, and first to fourth low pressure turbine stages were all damaged
- on the left side of the left hand engine was soot and oil
- on the fuselage were traces of oil
- the right main gear brakes were jammed
Pollution with engine oil was reported from the village of Harleem, the investigation however could not establish the source of the oil spill stating that the aircraft did not overfly the specific area in question.
Immediately after departure of the Boeing Schiphol operations were advised of a possible bird strike on runway 18L and recovered the remains of 7 dead Canada Geese, weights between 3 and 5 kg (6.6 to 11 lbs) from runway 18L around about the extended centerline of runway 06/24.
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Single pilot plus somebody on board for doing the radios....
It still amazes me how many of these people not only manage to get into the front seats, but manage to stay there. I wonder about the standards of training & checking.
Not wanting to flare up the cadet debate, but it is interesting to me to see the total time vs time on type numbers for both pilots.
interesting to me to see the total time vs time on type numbers for both pilots
Total: 7540 hours.
Boeing 737: 7200 hours.
Boeing 737 as captain: 2410 hours.
Total within Atlas Blue: 1218 hours.
Last 90 days: 217 hours.
Last 24 hours: 6.52 hours.
F/O
Total: 2730 hours.
Boeing 737: 2308 hours.
Total within Atlas Blue: 2147 hours.
Last 90 days: 250 hours.
Last 24 hours: 6.52 hours.
Official report
https://www.onderzoeksraad.nl/upload...b_10012012.pdf
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So let me get this straight :-
Captain had the grand total of 340hrs prior to moving onto Boeing 737.
F/O had slightly more at 422hrs.
Wow.
Based on the above info from Megan, the F/O is just about due for an upgrade to Captain!
Megan - I can't get that report link to work. I'm sure it makes interesting reading...
Captain had the grand total of 340hrs prior to moving onto Boeing 737.
F/O had slightly more at 422hrs.
Wow.
Based on the above info from Megan, the F/O is just about due for an upgrade to Captain!
Megan - I can't get that report link to work. I'm sure it makes interesting reading...
Last edited by IFEZ; 5th Jul 2017 at 00:43. Reason: Extra comments made
@IFEZ here in Europe it is not unusual to have trainees on the 737 with less than 200 hours of flight time, they are generally easy to train they don't have the engrained habits of an experienced air taxi pilot. They also of course need a great deal of supervision in the early days of line flying, being monitored by a safety pilot until such time as the Line Trainer decides they can manage without, it's not unusual to see them in the left seat with a little over 3000 hours total.
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they don't have the engrained habits of an experienced air taxi pilot
After 18 years of RAAF flying and following retrenchment from a 737 airline I applied for a job with a small charter operation out of Essendon flying the one and only MU2. The chief pilot quickly sneered that he would never employ ex RAAF because they would expect too much of the serviceability of the aircraft and not "be flexible" with defects. Not only that he said we would not be able to handle single pilot IFR. I deigned to tell him I had flown Mustangs and single seat Vampires single pilot IFR when I was only 21.
The irony of it all was when I went back to flying 737's on international routes, the same chief pilot became my first officer a few months later
It would have been boorish to bring that up in subsequent conversations so I avoided it
Centaurus, many thanks for drawing this fascinating incident to the attention of the forum. The authors of the report deserve a gold star for their language and wording, in their recommendations: "The Safety Board recommends that Royal Air Maroc demonstrate to the Moroccan Ministry of Transport that: 1. the procedures for communication and crew resource management between crew members have been harmonised with the international standard for airline pilots. 2. pilot training has been expanded to include simulations of multiple unexpected failures." Harmonise: what a delightful way of making their point. I will remember that and use it in reports I write.
Harmonise: what a delightful way of making their point. I will remember that and use it in reports I write.
Centaurus, I speak as I find and my experience showed me that a significant number of the experienced pilots were harder to train, ex forces or ex air taxi made no difference it wasn't generally a lack of ability but an attitude problem. Most listened learnt the SOPs, the flight profiles and checklist responses and arrived at the sim looking to learn and do the best they could, taking this attitude into line training, others were far to keen to explain that they didn't do it that way on their previous type civil or military. Your MU2 aviator sounds like he would have been a pain in any sort of aircraft.
