Luxair F50 Crash: Pilot's Fault
Pegase Driver
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very good post LEM. You are right about macho behaviour of the past and todays sometimes weak capts .
Just a correction, In Tenefiffe, the Pan am capt did shout " we are still on the runway " or something to that extend but the call was crossed with the TWR call to try to stop the KLM...
Just a correction, In Tenefiffe, the Pan am capt did shout " we are still on the runway " or something to that extend but the call was crossed with the TWR call to try to stop the KLM...
What the Captain really means
There is substance in what LEM states, but what the “Captain really means” is that we all require airmanship and need to continuously improve our personal standards. However what about the other crew members? There was an indication in this accident that the co-pilot did appreciate the tight situation, but he was unable to break the Captain’s line of thinking, therefore co-pilots also require additional training.
Try these as examples, taken from Capt (Dr) Bob Besco’s paper “PACE”.
Probing - for a better understanding.
Alerting - the Captain of the anomalies.
Challenging - the suitability of present strategy.
Emergency Warning - of critical and immediate dangers
Probing
Captain, I need to understand why we are flying like this.
Aren't you putting yourself into a corner and aiming to shoot yourself in the foot.
Alerting
Captain, it appears to me that we are on a course of action that is drastically reducing our safety margins and is contrary to both your briefing and to company's SOPs.
It is my function and responsibility to protect your blind spots. I see you are about to walk off a cliff.
Challenging
Captain, you are placing the passengers and aircraft in immediate danger. You must choose a course of action that will reduce our unacceptably high risk levels.
You are about to self destruct. You have the equivalent of a very angry and armed bogey in your six o'clock position. We are all about to get the civil aviation equivalent of a 20 mil enema.
Emergency
Captain, if you don't immediately increase our safety margins, it is my duty and responsibility to immediately take over control of the airplane.
You, your airplane and every one on board are about to be dead meat. I choose not to join you. If you don't immediately cease and desist, I will take the airplane away from you. I owe it to myself, my family, our passengers, and our company to restore an adequate margin of safety.
The complete paper is here.
--------------------
Unless specifically authorized everything else is forbidden.
Try these as examples, taken from Capt (Dr) Bob Besco’s paper “PACE”.
Probing - for a better understanding.
Alerting - the Captain of the anomalies.
Challenging - the suitability of present strategy.
Emergency Warning - of critical and immediate dangers
Probing
Captain, I need to understand why we are flying like this.
Aren't you putting yourself into a corner and aiming to shoot yourself in the foot.
Alerting
Captain, it appears to me that we are on a course of action that is drastically reducing our safety margins and is contrary to both your briefing and to company's SOPs.
It is my function and responsibility to protect your blind spots. I see you are about to walk off a cliff.
Challenging
Captain, you are placing the passengers and aircraft in immediate danger. You must choose a course of action that will reduce our unacceptably high risk levels.
You are about to self destruct. You have the equivalent of a very angry and armed bogey in your six o'clock position. We are all about to get the civil aviation equivalent of a 20 mil enema.
Emergency
Captain, if you don't immediately increase our safety margins, it is my duty and responsibility to immediately take over control of the airplane.
You, your airplane and every one on board are about to be dead meat. I choose not to join you. If you don't immediately cease and desist, I will take the airplane away from you. I owe it to myself, my family, our passengers, and our company to restore an adequate margin of safety.
The complete paper is here.
--------------------
Unless specifically authorized everything else is forbidden.
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Safetypee
just to confirm, FDM is installed and is in use, but only on the 737 and E145 fleet. It is not installed on the F50. The processing of the data is done, but since FDM has been introduced only about a year ago, it is still not used to its full capacity.
That management pretends that the pilot union is against the introduction is a mere lie, as you can see from my previous statements. The pilot union asked Management in summer to stop using FDM, as there was a breach of confidence ( see Flight International this and last week), but management did not comply with the request.
As to the reason of the crash, it was not the shutdown of the engines, but the propellers entering beta range that started the fatal sequence. The shutdown, as part of the restart procedure, was rather the attempt to find a way out of the fatal situation. (BTW from the FDR data I can see only one engine (left) that was shut down).
just to confirm, FDM is installed and is in use, but only on the 737 and E145 fleet. It is not installed on the F50. The processing of the data is done, but since FDM has been introduced only about a year ago, it is still not used to its full capacity.
That management pretends that the pilot union is against the introduction is a mere lie, as you can see from my previous statements. The pilot union asked Management in summer to stop using FDM, as there was a breach of confidence ( see Flight International this and last week), but management did not comply with the request.
As to the reason of the crash, it was not the shutdown of the engines, but the propellers entering beta range that started the fatal sequence. The shutdown, as part of the restart procedure, was rather the attempt to find a way out of the fatal situation. (BTW from the FDR data I can see only one engine (left) that was shut down).
Kmark thanks for the update on FDM.
I do not agree with your simplified assessment for the reason for the crash – the propellers entering beta range. Both props did go into beta and the aircraft descended, but it appears that at some point the left prop was recovered to the normal range (it was found to be in the feathered position). The FDR stopped at approx 900 ft agl when both engines were stopped.
Thus, as a hypothesis, as we cannot be sure, the aircraft could still have been flown with the right engine shut down and the left working normally. The airspeed remained high, thus there should not have been a problem with control (Vmca/Vmcl). The flaps were retracted to reduce drag. The unknown was if the left engine would have produced enough thrust to over come the drag of the right prop in reverse.
I agree with ALF5071H’s post on 16 Dec. The report confirms that both engines had been shut down, and if a shut down is the logical drill for an over speed, for which there is no evidence that the crew detected or that a drill exists, then only the right engine should have been shut down, certainly not both at 900 ft. No explanation was given in the report as to why both engines were stopped.
For at least one engine this appears to be ICR after a crew induced PSM.
I do not agree with your simplified assessment for the reason for the crash – the propellers entering beta range. Both props did go into beta and the aircraft descended, but it appears that at some point the left prop was recovered to the normal range (it was found to be in the feathered position). The FDR stopped at approx 900 ft agl when both engines were stopped.
Thus, as a hypothesis, as we cannot be sure, the aircraft could still have been flown with the right engine shut down and the left working normally. The airspeed remained high, thus there should not have been a problem with control (Vmca/Vmcl). The flaps were retracted to reduce drag. The unknown was if the left engine would have produced enough thrust to over come the drag of the right prop in reverse.
I agree with ALF5071H’s post on 16 Dec. The report confirms that both engines had been shut down, and if a shut down is the logical drill for an over speed, for which there is no evidence that the crew detected or that a drill exists, then only the right engine should have been shut down, certainly not both at 900 ft. No explanation was given in the report as to why both engines were stopped.
For at least one engine this appears to be ICR after a crew induced PSM.
Top Dog
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Just found this
23-MAR-04 Strike threat at Luxair?
Luxair passengers could face disruption to flights if pilots and cabin crew vote in favour of strike action. The Wort has learned that the LCGB union has initiated strike proceedings at Luxair, writing to pilots and cabin crew asking about their readiness to go on strike. Union attempts to discuss problem areas with the Luxair management have failed, and employee confidence in the management has disappeared because of its behaviour after the Fokker 50 crash, according to the Wort. The union also believes the management has destroyed the entire safety culture at Luxair.
Link
23-MAR-04 Strike threat at Luxair?
Luxair passengers could face disruption to flights if pilots and cabin crew vote in favour of strike action. The Wort has learned that the LCGB union has initiated strike proceedings at Luxair, writing to pilots and cabin crew asking about their readiness to go on strike. Union attempts to discuss problem areas with the Luxair management have failed, and employee confidence in the management has disappeared because of its behaviour after the Fokker 50 crash, according to the Wort. The union also believes the management has destroyed the entire safety culture at Luxair.
Link
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Call me naive, but why aren't F50 systems designed so that it is impossible to enter Beta range in flight, e.g. impossible to do it unless a/c senses it is "on ground"?
I know of several Casa 212s which crashed because the Beta stops were malfunctioning, and when crew throttled back on approach, it went into Beta range, and they were too low to recover. All claims settled out of court though, and the problem was fixed without publicity.
I know of several Casa 212s which crashed because the Beta stops were malfunctioning, and when crew throttled back on approach, it went into Beta range, and they were too low to recover. All claims settled out of court though, and the problem was fixed without publicity.
LUXury is a 13,000 ft runway
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Frangible:
Read the accident report - Luxair didn't implement on their F50s what Microsoft would call a "security update", and thus the Captain of the flight could fiddle with the prop blade angles more than was good for the aircraft (a/c was high and fast when cleared to land at LUX, to slow down Capt. (PF) overrides safety dev., nothing happens at first but then prop blades go to ground idle the moment the FO confirms "Gear down".
)
CR2:
Yeah, right, safety culture...
(though the sacking of the six pilots/management pilots nevertheless looks like a cover-your-
exercise for the current managment to me)
Read the accident report - Luxair didn't implement on their F50s what Microsoft would call a "security update", and thus the Captain of the flight could fiddle with the prop blade angles more than was good for the aircraft (a/c was high and fast when cleared to land at LUX, to slow down Capt. (PF) overrides safety dev., nothing happens at first but then prop blades go to ground idle the moment the FO confirms "Gear down".
)CR2:
Yeah, right, safety culture...
(though the sacking of the six pilots/management pilots nevertheless looks like a cover-your-
exercise for the current managment to me)
