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A310 fatal blind following of the the flight director

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A310 fatal blind following of the the flight director

Old 28th Feb 2018, 13:08
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A310 fatal blind following of the the flight director

https://www.skybrary.aero/index.php/...02be-276530305

Flight directors are reliable and amazingly accurate. But this accident report pertaining to an A310 undertaking a circling approach at night, revealed the crew were relying heavily on the autopilot and FD indications to fly the aircraft. After mis-programming and initially blindly following the flight director indications without cross-referencing other flight instruments, the aircraft descended to a dangerously low altitude before the crew disconnected the autopilot and went around. The crew immediately re-engaged the automatics and lost situational awareness and allowed the aircraft to pitch up under high thrust and stalled. The aircraft crashed into the sea.
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Old 28th Feb 2018, 16:22
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Yemen, not exactly known for its feelgood stories. Although, The survival of Bahia Bakari is an extraordinary tale.

The Australian, 28 Dec 2009: She clung to a piece of metal, gasping for breath in the waves. Somewhere in the darkness she heard cries for help, but the voices soon faded. Hours later, when the sun came up, Bahia Bakari, a 13-year-old schoolgirl, was adrift alone in the Indian Ocean.
In the middle of her makeshift raft, a piece of aircraft fuselage, she noticed a porthole and peered through it into the inky depths. The sight of dark shapes moving below filled her with terror. "I couldn't bear it any longer. I couldn't move any more. It was the end. I closed my eyes."

The "miracle girl" was the sole survivor of a plane crash in which 152 people, including her mother, were killed on June 30. For the first time, she has given a detailed account of her ordeal, describing in a book how she drifted for 13 hours before being saved from shark-filled waters off the Comoros Islands, near Madagascar.

Her ghosted memoir, to be published next month, describes her surprise on discovering she had been in a plane crash. Until arriving in hospital she was convinced, in her state of shock, that she had fallen from the aircraft after pressing too hard with her forehead against a window.

As Bahia rose and fell in the waves, she believed that Aziza, her mother, had landed safely and would be "worried to death" about her - as well as angry with her for falling out of the plane and not putting on her seatbelt.

The two had set out from Paris the day before. After a stop in Marseilles they had changed to an Airbus A310 in Yemen for the onward Yemenia flight to Moroni, capital of the Comoros. The cause of the crash has yet to be determined, but the doomed plane had been banned from operating in France. "It smelt of the loo," Bahia writes. "There were flies."

As they were descending into Moroni, the plane began to tremble and the hostesses seemed "nervous". The cabin lights went on and off and the aircraft began to buck about in the air.

Bahia pressed her forehead against the porthole to see if she could see the lights of Moroni. Then what felt like a surge of electricity convulsed her body. "I wanted to call Mummy but my body felt stretched to the maximum, about to explode," she writes. "Then there was a great noise, enormous, unbearable, like a gigantic explosion."

The next thing she knew she was in the water, coughing, choking, gasping for breath.

"It was dark, a night with no moon, but I saw four pieces of white debris floating not far from me," she writes in A Day Like Any Other, to be published by Jean-Claude Gawsewitch in Paris. "I managed to swim towards the biggest one."

She tried to climb on to it, but the metal tipped over when she pressed down on one side. She contented herself with lying across it, her legs in the water.

She heard women crying out for help and tried to move towards them so as not to be alone, but her arms hurt when she paddled and, in any case, she could see nothing. The voices stopped after a while.

When she heard the sound of an aircraft passing overhead she was convinced that rescuers would come. On the crest of one wave, she got a glimpse of green hills on the horizon.

After a while it became clear that she was drifting away from land instead of towards it. She began to despair of anyone ever finding her in "this immensity". Her strength began to fail and her thoughts became confused. She felt on the verge of giving up. Then she looked up. Struggling through the waves in her direction was a boat. She tried to shout. Word of the crash had spread fast and dozens of boats had taken to the sea in a hunt for survivors. Libouna Matrafi, a fisherman, stood at the bow of a small boat, staring in amazement at the girl hanging on to a piece of fuselage.

Bahia had let go of her raft. She was trying to swim towards her rescuers when she was swamped by a wave. Matrafi jumped into the sea and swam towards her. He pushed her up into the arms of his companions before being swept away by the waves. He was more than 100m away by the time the boat turned back to fetch him.

Safely aboard, Bahia was given water and wrapped in blankets. It took several hours in increasingly turbulent seas to get back to port. One of the crew, not wanting Bahia to be anxious, told her that her mother had already been picked up by another boat.

In hospital Bahia discovered that besides the cuts, bruises and burns on her legs, she had a fractured pelvis and collarbone. She expected at any moment to see her mother.

A female psychologist came to see her. It would be normal, she said, for Bahia to feel guilty for having survived the crash. Not understanding the reference to a crash, Bahia asked again after her mother. "You know," replied the psychologist, "I don't think they've found your mother. They only found you."

The truth began to dawn on Bahia. "Those words hurt me more than the crash, more than the terrible wait in the cold night alone in the middle of the ocean," she writes. "I was amazed by . . . the almost casual tone in which she announced that I would never again see my mother. I began to understand the atrocious reality: I was not the only one to fall from the plane. All of the passengers, the pilot, the crew, had fallen from the plane. Mummy, she fell from the plane too, like me, perhaps right next to me."

For a while Bahia hoped her mother would also be found safe, but rescue efforts had all but ceased because of severe weather.

The French minister for overseas territories arranged to take Bahia back to Paris on his plane for treatment. Despite her unease at flying so soon after the disaster, she agreed, eager to see her father.

She spent three weeks in hospital. One of the first visitors was French President Nicolas Sarkozy. She is happy to have been reunited with her siblings but is being counselled by psychologists in case she suffers post-traumatic stress. Her mother's body was one of 84 recovered from the sea.

Bahia is looking forward to meeting Matrafi, the man who saved her and who is applying for French residency after being decorated for bravery.

He recently sent her a taped message. "Hello Bahia, I just wanted to say hello and to ask about your health and that of your sister and brothers," he said. "Thank God you are alive."

The only time she had seen Matrafi's face was when he fixed her with his gaze as he approached through the waves with a life buoy in his hand.

"I try, at night, to remember his face," she says, "so as never to forget it. He is a hero."
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Old 28th Feb 2018, 19:19
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Relying on automatics and not cross-referencing? Would never happen in Australia.
Wrong flight coordinates almost sent QF720 into mountainside

Air-safety authorities are investigating a dramatic incident in the skies south of Canberra in which a near-fully laden Qantas jet narrowly missed crashing into a mountain. The Australian Transport Safety Bureau is investigating the incident involving Qantas Flight 720 which left Perth at 12.05am on July 24 to fly direct to Canberra. The aircraft, a Boeing 737-800 and one of the newest additions to the Qantas fleet with a fully computerised cockpit and fly-by-wire controls, was understood to be carrying 155 passengers and crew. An unconfirmed report, posted on a professional pilots' Internet site, described the circumstances in which the airliner on automatic pilot at 5000 feet came within 80m of hitting a mountain peak in the Tinderry ranges, about 40km south of Canberra.

Qantas, the ATSB and the Civil Aviation Safety Authority all confirmed an incident took place but were unwilling to provide specific details. Nor will authorities acknowledge - as the web site reported - that the jet's last line of defence against hitting terrain, its Ground Proximity Warning System, was the only thing which saved the lives of everyone on board. In a terse statement issued last night by the Qantas head of flight operations, Captain Chris Manning, the airline said that ''the information on the web site is factually incorrect''.''

Qantas reported the incident promptly to the ATSB and is co- operating fully with the ATSB investigation,'' he said. What has not been explained is why the ATSB has taken nearly two months to issue a preliminary report on the incident. This report, it says, will be issued ''in a couple of days''.

A CASA investigator directly handling the report was not available for comment last night, but a spokesman for the authority said that ''it appears the incident, as described on the web site, is somewhat exaggerated''. The web site tells how the Qantas jet - ahead of schedule because of a tailwind - went into a routine holding pattern while awaiting the opening of the Canberra Airport Traffic Control Tower at 5am. It appears the problems began when the wrong coordinates were programmed into the flight management computer, which directs the aircraft into a programmed holding pattern around a specific GPS way point. The height of this holding pattern was reported to be 5000ft.

Under normal circumstances, the centre of this ellipse-shaped holding pattern would be Canberra Airport. However, for reasons which are still under investigation, the central point of the holding pattern was programmed much further south, most likely a locator beacon to the south-west of Googong Reservoir. This meant that the aircraft's pattern centred on a position about 19km south of the airport, with its looping path taking it south directly into the Tinderry Mountains, which has its highest point as Tinderry Peak (1619m, or 5311ft).

With the airliner flying in darkness at a minimum 180 knots at 5000ft, 300ft below the height of the tallest peak in the mountain range, the sudden activation of the GPWS system would have come as an ''enormous shock'' to the air crew, experienced pilot and former Civil Aviation Authority chairman Dick Smith said. ''What we have got here is the most serious near-accident we've had in nearly 30 years,'' Mr Smith said. The incorrect programming of the computer was probably compounded by the failure of the air traffic control system to notice the dangerous terrain, he said.

''What's even more alarming is the suggestion that since this incident occurred...Qantas has lifted the recommended height of its holding patterns to 6000ft - and not told any of the other airlines.'' Sources inside Qantas said last night that the investigation of the QF720 incident had used a cockpit simulator to duplicate the series of errors which led to the incident and to assess the pilot's response.
As I recall, the official findings were that “there was never a risk to passengers” and that everyone should move on - nothing to see here.
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Old 28th Feb 2018, 21:16
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Lead Balloon, you obviously don't know that that quote is full of rubbish. Check your facts first. Had you read the final report before quoting that claptrap, you may have toned-down your (typical) sniping invective.
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Old 28th Feb 2018, 22:11
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Would that be the “final report” of the oh-so-independent and credible ATSB, Bloggsie? Or the “final report” of the oh-so-disinterested operator?

Since you seem to know all the facts and purport to be objective, was any mistake made by the crew? If yes, what was that mistake?

If a mistake was made, did it result in any increase in risk the the POB? If yes, why? If not, why not?
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Old 28th Feb 2018, 22:19
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Ignore button click.
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Old 1st Mar 2018, 01:47
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Since you seem to know all the facts and purport to be objective, was any mistake made by the crew? If yes, what was that mistake?

If a mistake was made, did it result in any increase in risk the the POB? If yes, why? If not, why not?
Written like a typical CASA desk jockey lawyer.

When it comes to flight deck issues you are out of your depth. Stick to ad nauseum discussions of Australian airspace.

The discussion is on cross referencing FDs to other flight instruments not another ATSB bash.

IMHO the FDs are for me to reference, not to follow.
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Old 5th Mar 2018, 03:46
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Flight Directors – A Fatal Attraction

The discussion is on cross referencing FDs to other flight instruments not another ATSB bash.

IMHO the FDs are for me to reference, not to follow.
My first encounter with flight directors was in 1966 while undergoing conversion to the Avro 748. The RAAF had seen fit to send me to Woodford in Cheshire, all the way from Australia to ferry the second of several new 748’s for the RAAF VIP squadron at Canberra. The conversion was conducted on a battered 748 demonstrator G-ARAY known as Gary. The contract allowed four hours of dual for the captains and nothing for the co-pilots. G-ARAY had the basic instrument flying panel of that era and no flight director.

Our instructors at Avro’s were well known test pilots Bill Else, Tony Blackman and Eric Franklin. Jimmy Harrison was chief test pilot. Unlike the bog-standard civilian 748, the RAAF 748’s were to be equipped with a Collins FD 108 FD. So the situation existed that the RAAF 748’s had a British Smith’s autopilot system which was married (somewhat expensively and painfully) to the American Collins FD 108. For the life of me I could not see why a flight director was needed in the RAAF 748. After all, the approach speed was that of a DC3 – 80 knots and the aircraft a delight to handle compared with the venerable Dakota.

In retrospect, I think the old Wing Commander Transport Ops at Department of Air, who was charged with the procurement of the 748 for RAAF service, and hadn’t flown for years, was perhaps conned by the Avro sales people in conjunction with Collins, into buying the Collins systems. Certainly in my view as the squadron QFI, flight directors were not operationally needed. In the event, the RAAF machines came with Collins FD 108 flight directors and as the contract specified each captain would be given only one hour of dual instruction once the 748 came out of the factory, we needed to learn how to operate the FD.

First, a course was arranged at the Collins establishment at Weybridge in Surrey. The two RAAF captains and their co-pilots attended and our two navigators and our instrument fitters also turned up to enjoy the Collins hospitality. We learned about 45 degree automatic intercepts of the VOR and ILS beams and other goodies including V-bar interpretation. We were showered with glossy brochures of the flight director by white dust-coated lecturers and shown a film. By lunch time the presentation was complete and we were shouted to a slap up pub meal with lots of grog, all paid for by Collins. We asked what further lectures were to take place after lunch. We were told the course was over – it was just a morning’s job and we were free to leave unless we would like more drinks. Naturally it was churlish to refuse and hours later we staggered to the railway station (I think), smashed to the eye balls and having forgotten all about the marvels of 45 degree auto intercepts on the FD 108. I must say it was a bloody good three hour course what with the free grog and all that.

A few weeks later, I flew the second RAAF aircraft out of the factory, A10-596, under the watchful eye of Eric Franklin DFC and he demonstrated flight director stuff. For example to climb using the FD, you first put the aircraft into a normal climb and when settled you switched on the FD and carefully wound up the pitch knob so that the little aeroplane sat in the middle of the V-bars. I quickly realised that you hand flew the basic artificial horizon to whatever attitude was appropriate for the manoeuvre then told the FD 108 V bars where you wanted them. The ILS intercept of 45 degrees was never used because radar vectors didn’t do such angles.

I became more and more convinced the 748 didn’t need flight directors and that they were a load of bollocks in that type of low speed aircraft. We were told the USAF used the FD 108 in its F4 Phantoms and that Collins was anxious to makes sales in the UK market. The RAAF Wing Commander got sucked in by good sales talk and from then on all RAAF 748’s became so equipped. I held personal doubts about the usefulness of flight directors in general as I could see even then, their extended use could lead to degradation of pure instrument flying skills.
Today’s flight director systems are light years ahead in sophistication compared with the old Collins FD 105 and 108 series. But the problem with blind reliance on FD indications and thus steady degradation of manual instrument flying skills is as real now as it was back in 1966.

Now to the present day - although first some background history. First published in 1967, “Handling the Big Jets” written by the then British Air Registration Board’s chief test pilot David Davies, is still considered by some as the finest treatise still around on jet transport handling. Indeed, the book was described by IFALPA as `the best of its kind in the world`…written by a test pilot for airline pilots, the book is likely to become a standard text book…particularly recommended to all airline pilots who fly jets in the future…valuable to those pilots who are active in air safety work”.

All that was back in 1967 and little has changed since then - apart from an increasing propensity for crashes involving loss of control rather than simply running into hills. LOC instead of CFIT. Mostly these accidents were caused primarily by poor hand flying and instrument flying skills which certainly explains why aircraft manufacturers lead the push for more and more automatics. A colleague involved with Boeing 787 training was told by a test pilot on type, that the 787 design philosophy was based on the premise that incompetent crews would be flying the aircraft and that its sophisticated automatic protection systems were in place to defend against incompetent handling. Be it a tongue-in-cheek observation, it contains an element of truth. With the plethora of inexperienced low hour cadet pilots going directly into the second in command seats in many airlines in Asia, the Middle East and Europe, these protection systems are important.

Towards the end of his book, Davies discusses the limitations of the flight instruments in turbulence and in particular the generally small size of the active part of the basic attitude information or the ‘little aeroplane” as many older pilots will remember it. He continues: “the preponderance of flight director and other information suppresses the attitude information and makes it difficult to get at” and “the inability, where pitch and roll information is split, to convey true attitude information at large pitch and roll angles in combination” Finally Davies exhorts airline pilots “not to become lazy in your professional lives…the autopilot is a great comfort, so is the flight director and approach coupler…but do not get into the position where you need these devices to complete a flight”. There is more but go and read the book.

Having done the unforgiveable and quoted freely from an eminent authority, it is time to say something original and accept the no doubt critical comment that is freely available. Flight Directors can be a fatal attraction to those pilots who have been brain-washed by their training system to rely on them at all times. While Boeing in their FCTM advise pilots to ensure flight director modes are selected for the desired manoeuvre, it also makes the point that the FD should be turned off, if commands are not to be followed.

Recently a new pilot to the Boeing 737 asked his line training captain if he could turn off the FD during a visual climb so he could better “see” the climb attitude. His request was refused as being “unsafe” and instead he was told to “look through” the FD. I don’t know about you, but I find it impossible to “see” the little aeroplane when it is obscured by twin needles or V-bars. In fact it takes a fair amount of imagination and concentration to do so. Which may be why Boeing recommends pilots to switch off the FD if commands are not to be followed.

I well recall my first simulator experience in the 737 of an engine failure at V2 where I was having a devil of a time trying to correct yaw and roll and the instructor shouting at me to “Follow the bloody flight director needles”. I learned a good lesson from that tirade of abuse on how not to instruct if ever I became a check pilot. In later years, having gravitated to the exalted – or despised maybe – role of simulator instructor, my habit was to introduce the engine failure on take-off by first personally demonstrating to the student how it should be done on raw data; meaning without a flight director. I hoped by first demonstrating, the student could see the body angles or attitude rather than imagine them by trying to “look through” the dancing needles of the FD. I have always been an advocate of the Central Flying School instructional technique of demonstrate first so the student then knows what is aiming for. Of course in the simulator, the instructor runs the risk of stuffing up (been there - done that!) but it at least proves he is human and not just another screaming skull.

Recently, a 250 hour pilot with a type rating on the 737-300 and trained overseas, booked a practice session prior to putting himself up to renew an instrument rating. His last rating was on a B76 Duchess. As part of the 737 instrument rating would include manual flying on raw data, he was given a practice manual throttle raw data take off and climb to 3000 ft. He protested, saying he had never flown the simulator without the flight director. His instructions were to maintain 180 knots with Flaps 5 on levelling. He was unable to cope and when the instructor froze the simulator to save more embarrassment, the student was 2000 ft above cleared level and 270 knots still accelerating with take off thrust. The student had been totally reliant on following flight directors with their associated autothrottles during his type rating course and without this aid he was helpless. I believe this is more widespread than most of us would believe; especially as we tend to move in our own narrow circle of experience.

At a US flight safety symposium, a speaker made the point that it is the less experienced first officers starting out at smaller carriers who most need manual flying experience. And, airline training programs are focused on training pilots to fly with the automation, rather than without it. Senior pilots, even if their manual flying skills are rusty, can at least draw on experience flying older generations of less automated planes.

Some time ago, the FAA published a Safety Alert for Operators (SAFO) entitled Manual Flight Operations. The purpose of the SAFO was to encourage operators to promote manual flight operations when appropriate. An extract from the SAFO stated that a recent analysis of flight operations data (including normal flight operations, incidents and accidents) identified an increase in manual handling errors and “the FAA believes maintaining and improving the knowledge and skills for manual flight operations is necessary for safe flight operations.”
Now let me see, I recall similar sentiments nearly 50 years ago published in “Handling the Big Jets” when David Davies wrote ” that airline pilots should “not become lazy in your professional lives…the autopilot is a great comfort, so is the flight director and approach coupler but do not get into the position where you need these devices to complete the flight.” See my earlier paragraphs.

It is a good bet that lip service will be paid by most US operators to the FAA recommendation to do more hand flying. It may have some effect in USA but certainly the majority of the world’s airlines, if they were even aware of the FAA stance in the first place (very doubtful), will continue to stick with accent on full automation from lift off to near touch-down and either ban or discourage their pilots from hand flying on line. If you don’t believe that, consider the statement in one European 737 FCOM from 20 years ago that said: “Under only exceptional circumstances will manual flight be permitted” After all, when at least two major airlines in SE Asia have recently banned all take off and landings by first officers because of their poor flying ability, then what hope is there to allow these pilots to actually touch the controls and hand fly in good weather?

One of those airlines requires the first officer to have a minimum of five years on type before being allowed to take off or land while the other stipulates the captain will do all the flying below 5000 ft. It might stop QAR pings and the captain wearing the consequences of the first officer’s lack of handling ability, but it sure fails to address the real cause and that is lack of proper training before first officers are shoved out on line.

I think the FAA missed a golden opportunity in its SAFO to note that practicing hand flying to maintain flying skills will better attain that objective if flight director guidance is switched off. The very design of flight director systems concentrates all information into two needles (or V-bar) and in order to get those needles centred over the little square box, it needs intense concentration by the pilot. Normal instrument flight scan technique is degraded or disappears with the pilot sometimes oblivious to the other instruments because of the need to focus exclusively on the FD needles. Believe me we see this in the simulator time and again. Manual flying without first switching off FD information will not increase basic handling or instrument flying skills.

The flight director is amazingly accurate provided the information sent to it is correct. But you don’t need it for all stages of flight. Given wrong information and followed blindly, it becomes a fatal attraction. Yet we have seen in the simulator a marked reluctance for pilots to switch it off when it no longer gives useful information. Instructors are quick to blame the hapless student for not following the FD needles. This only serves to reinforce addiction to the FD needles as they must be right because the instructor keeps on telling them so. For type rating training on new pilots, repeated circuits and landings sharpen handling skills. Yet it not uncommon for instructors to teach students to enter waypoints around the circuit and then exhort the pilots “fly the flight director” instead of having then look outside at the runway to judge how things are going.

First officers are a captive audience to a captain’s whims. If the captain is nervous about letting his first officer turn off the flight director for simple climbs or descents, or even a non-threatening instrument approach, then it reflects adversely on the captain’s own confidence he could handle a non-flight director approach. The FAA has already acted belatedly in publicly recommending that operators should encourage more hand flying if conditions are appropriate. But switch off the flight directors if you want real value for money particularly with low hour pilots. It may save lives on the proverbial dark and stormy night and the generators play up.
……………………………………
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Old 7th Mar 2018, 20:31
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Centaurus,

Yet another well written, highly informative and thought provoking post.

Thank you....
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Old 8th Mar 2018, 00:18
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Great article
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Old 8th Mar 2018, 03:14
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Originally Posted by Centaurus
Flight Directors – A Fatal Attraction

(snipped)

Absolutely tremendous, very interesting and designed to make people consider, ponder and think. Thank you for taking the time to write something so important. This level of awareness around the traps of automation and over-dependence on technology is now getting less and less prevalent as people with your level of practical life experience are rapidly disappearing. Much appreciated reading something with such solid reasoning and obvious real-world knowledge.
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