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Boeing 737 dark night crash in 2004 caused by automation dependence

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Boeing 737 dark night crash in 2004 caused by automation dependence

Old 22nd Aug 2017, 13:53
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Boeing 737 dark night crash in 2004 caused by automation dependence

Minutes after take-off from Eygpt's Sharm el-Sheikh airport on 3 January 2004, a Boeing 737-300 operated by Egyptian charter company, Flash Airlines, crashed into the Red Sea at high speed. All 142 passengers and the six crew were killed. The accident happened in early morning darkness.

CVR evidence revealed the captain called for the autopilot to be engaged shortly after take-off. Because of slight pressure on the control wheel being held by the captain, when the first officer tried to engage the autopilot it did not engage. However, the captain thought the autopilot had been engaged and released control. From then on there was confusion in the cockpit and the aircraft being slightly out of trim began to turn and eventually reached a bank angle of 111 degrees and 40 degrees nose down.

The captain in a state of panic continued to call for the autopilot to be engaged until the 737 hit the sea at 416 knots only eight nm south of the airport. There is little doubt the captain lacked the basic instrument flying skills to recover from the unusual attitude of his own making because of his total reliance on automation to fly the aircraft.

Although this accident happened over 13 years ago and was just one of several jet transport CFIT crashes that eventually led to the call for better training in unusual attitude recoveries, there are many operators that still require full use of automation from immediately after take-off to shortly before landing to the detriment of manual instrument flying skills.
The Egyptian report said the cause of the aircraft's dive into the Red Sea remained uncertain. Findings listed as `possible causes` included an aileron trim runaway and a hard-over autopilot actuator. Two other agencies (the French BEA and US NTSB) took issue with the Egyptian findings. The NTSB, in a letter to the Egyptian Ministry of Civil Aviation maintained there was `no evidence that an airplane- related malfunction or failure caused or contributed to the accident`.

Both the French and US investigators concluded that the CVR script and flight profile indicated that the captain became spatially disoriented during the night departure and the first officer did not assume timely control of the aircraft because he was unwilling to challenge his far more experienced superior

See link to the official accident report.
https://www.fss.aero/accident-report...4-01-03-EG.pdf

Last edited by Centaurus; 22nd Aug 2017 at 14:14.
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Old 22nd Aug 2017, 20:14
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Join Date: Jul 2008
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Both pilots in VOR mode and nobody with MAP. Inexperienced F/O, steep cockpit gradient, dark night, early turn. Lots of little flags popping up. Another one is the fact the Captain had flown Russian equipment. I can never get my head around Russian ADI's. Totally arse up in my opinion.
To lose it so quickly seems a little strange especially with no signs of a recovery as the nose goes down.
Thanks 'Centaurus' all good information to reflect on.
By George is offline  
Old 23rd Aug 2017, 19:30
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Join Date: Nov 2009
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I seem to remember you and I giving ourselves a fright on a dark night departure, George. All my fault as I recall!
Dora-9 is offline  
Old 24th Aug 2017, 07:56
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And another two -


https://reports.aviation-safety.net/...738_ET-ANB.pdf


https://aviation-safety.net/database...?id=20070505-0


The Kenya Airways report is in French, however, it appears to be yet another case of trying to engage the autopilot & failing, coupled with an inability to hand fly the aircraft on instruments.
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Old 24th Aug 2017, 08:20
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That was nothing to some of the frights in SE Asia Dora and we are still here!

On the subject of hand flying, I remember being shouted down about the value of light twin time. "What has a 40 year old clapped out Baron got to do with flying a jet?" they said. I agree, not much, but single pilot IFR with a lousy auto-pilot did teach you 'flying on Instruments'.
By George is offline  

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