Luxair F50 Crash: Pilot's Fault

[LEM]

I just watched the tv: they've issued some sort of final report:

"Total lack of coordination, planning, started the approach when not ready, violated all the rules in the manuals..."

I personally never got to know what happened exactly.
Any informed colleague?

[answer=42]

extract from technical report (not final version, apparently):
http://www.rtl.lu/news/temp/luxair/

[opsmaneurope]

Talking to friends in LUX earlier this year I understood it was pilot error, however this was compounded because LG hadn't carried out a modification to prevent the such happening.

[ATC Watcher]

Sorry folks but I read the " causes" part as shown in the web site more as a total failure of the Airline in providing training, proper CRM, and in distribution of essential info to their crews, rather than just " Pilot error " .
Of course it will always ultimately be the guy at the control who screw things up, but why and how did he arrive to this is the crucial question.
I guess some heads are going to roll at Luxair if what we read in the web site is indeed in the final report .

This sounds very similar to the collision in July 2002 in Ueberlingen.. first blame the persons at the controls,( Swiss controller or even Russian pilot ) but the failures were largely in management as the final report will show.

[411A]

Management flying the aeroplane ...(think not).
If pilots cannot keep the blue side up, it is hardly the fault of 'management'.

How about...inattention as to what they (the pilots) were actually doing.



Wonder just when some pilots (providing they survive the crash) will start to actually wake up to the fact that, IF you are not up to speed, excuse yourself from the profession.

It would seem that common sense has gone out the window, especially with the 'lets talk it over' CRM crowd.
Horsepucky...fly the aeroplane, period.

[Wizofoz]

411A,

So I guess when YOUR operation is up and running (chortel, guffaw), you won't be providing such non-essentials as training, SOPs, CRM etc. You'll just wait for your Dino-Jets to spud in and then tell the enquiry "It was the crews fault".

Good luck getting insurance.

[acmi48]

the properties on the link are a .jpg file which means that somebody who understands english is of an airline background and connected has got his hands on something and used it for whatever reason

as far i know there is no official report yet as the case received and extended time from 1 year to publish .something smells around this

[answer=42]

Luxair reaction to leak of draft report

The following is from today's 'Le Quotidien' (no website that I can find):

Final report will be published 15 December.

Henri Grethen, Transport Minister said,
'The role of the Ministry is to verify that the licences are in order.' ... 'There is no text that says, to my knowledge, that the two pilots must be trained at the same school and must follow the same in-service training.' ... 'I am convinced that we have done what was required.'

This is my translation, the French text says,
'le rôle du ministère est de vérifier que les licences sont en règle.' ... 'Aucun texte ne dit, à ma connaissance, que les deux pilotes doivent être formés dans la même école et suive la même formation continue.' ... 'Je suis persuadé que nous avons fait ce qu'il fallait faire.'
Usual newspaper disclaimer applies.

[411A]

Wizofoz,

Management is responsible for providing the proper training, however cannot have a check pilot on every line flight.
IF line pilots fail to follow the standard operating procedures as required by the company, accidents happen.

Many examples in the past to prove this.


PS: Operating already, two aircraft...more added shortly.

[acmi48]

..there is an element of nepotism involved.. however the final result will always be.. the culture of those that feel the necessity
to be a figure head.in this case i would let sleeping dogs lie..and cast a caring word to those that lost the lives of someone they loved.the ALPL of luxembourg airlines in this case are right to ask for caution in the case of the aviation community


luxembourg is a safe place and the aviation community is united towards a safe and efficient air service.others who exploit this kind of incident do so for means far more sinister means

[DUKE101057]

I have a question.

Paragraph 3.2. Causes of the preliminary report reads: “The initial cause of the accident was the acceptance by the crew of the approach Clearance, also ….” Shouldn’t this be rather “The initial cause that TRIGGERED the accident was the acceptance by the crew of the approach clearance…” Personally I’d really hard to believe that this late and wrong decision may be THE CAUSE for a fatal accident …wrecks would pile up in final approach sectors? – Who never ever did wrong in his whole carrier? A CAUSE had brought you down too – did it?

Now, my question: Considering the facts listed under Contributory Factors, item number 4 of the same report, and considering the facts on the cockpit voice recorder and the flight data recorder, what had happened under exactly the same circumstances if:

A. ABSC SB F050-32-4 had been satisfactory complied with.
B. If only the vital safety information from the manufacturer to the operator, regarding the inherent risks of a potential loss of the secondary stop on the propeller pitch control had been forwarded in a satisfactory manner to the flight crews.

My mind is made up and accidents like this are only caused by people pretending in a self sufficient way that their place is safe, dear acmi48! It is more than time to wake up your dogs now since this hasn't even been the last in a long, long row of commercial flights accidents in little Luxembourg’s history!

[ATC Watcher]

411A my congratulations, when you comment on something you always manage to atract dozen of responses on a different issue.

Good luck with your copy of flying tigers, I'll be happy to jumpseat with you once the TSA relaxes its rules.

Now back to the topic, I agree management cannot put a check pilot behind every pilot, but if they ****ed up that big ( still to be proven BTW) then something is wrong with either the training , but surely with the profeciency checking mechanism wouldn't you say ?

Reading the annexes, and the CVR transcript ( at least this is not biased normally ) the key issues are laying in analysing the noises between 09.05.17 and 09.05 .25 when the capt says : " What is that ?" followed by the usual " Oh **** ! " just prior the end of the recording.

Do you believe that 2 pilots switched their 2 engines out on purpose or knowingly in that portion of the flight ?
If they did not, then we better find out what happenned and advertise it around to make sure no-one makes the same sequence of inputs in the future.

[411A]

ATC Watcher,

.
TSA absolutely has nothing to say about it.

Regarding the Fokker 50, wonder if someone here would comment on the procedure of selecting idle thrust in flight with these engines.

[alf5071h]

It is difficult to understand how the ‘leaked’ causes and recommendations have been assembled from the factual report. I assume that the missing parts of section 3 of the draft report will give an analysis and explain the logic used in the investigation, but on the data seen so far there appear too many illogical or flawed deductions.

I hope that the final report / investigators will address the following issues:
Did one or both propellers go into beta range during flight causing the aircraft to reduce airspeed (150-115), pitch nose down (-1 to -15), and loose altitude (2750 – 2100) such that the aircraft ultimately hit the ground? Thus this could have been a loss of control accident due to having reverse thrust in the air and ‘bunting’ (-0.5g) at low altitude. Following an apparent upset the crew may at a very late stage shut down one engine (fuel flow zero, LH prop rpm 5). Could they have encountered misleading power plant indications causing them to suspecting a failure? The crew appeared to be taking some corrective action – flap up and pulling nose up (less negative g: the elevator trace and lateral acceleration not shown).
A more extreme consideration would be that a pitch down after lowering flap is symptomatic of tail plane icing – recovery by pulling hard and retracting flap; is this to be formally discounted in the report?

What has not been clearly explained (or is not yet established / published) is why the propellers were in the beta range. Was this due to technical failure, or crew error in combination with a technical weakness (16 sec vulnerability when lowering the gear), or indeed a greater combination of these or other technical / organizational failures?
What is the logic in citing the crew’s late change of plan to continue the approach got to do with the cause other than they wished to slow down, they selected flight idle thrust, and lowered the flap and gear? If the technical weaknesses existed then the crew was just as vulnerable on this approach as any other.
Were the crew aware of the warnings about inadvertent or deliberate in-flight beta selections; how were they trained, did the documentation come with the aircraft?

Even with a comprehensive explanation and that in extremis the crew made an error, the rationale for the error must be presented before the recommendations can imply poor CRM or individual crew behavior. If the crew (crews) were inadvertently selecting beta in flight then an FDR monitoring program should have identified it, but so too would a LOSA program; furthermore LOSA would explain why the error was occurring. Deliberate, inadvertent, technical or a combination. Human error will occur in most operations; crews / organisations do not make errors deliberately, there is usually a complicated background to each event. What were the backgrounds to the errors in this accident?

I find it hard to understand why the anti skid manufacturer’s modification was only ‘optional’. Were they were more concerned about publishing that the mod was at the operator’s expense as opposed to closing down a safety weakness? It is not clear that the national authority mandated (must do) the mod, nor that they gave sufficiently strong advice about in flight beta awareness and avoidance training. Thus is an oversight program (Recc 4.3.1.1) equally applicable to the authority; as they audit the operators?

I hope that these points are answered with the publication of the final report. What the industry needs is information as to why crews make errors in emergency / unusual situations, not more reasons to blame them (and retrain them). The industry depends on the accident investigators to deliver this data.

Keep monitoring this thread.

[Captain Stable]

411A, selecting idle thrust is a matter of routine - as it is on any aircraft.

[411A]

Capt'n Stable

If you had flown many older heavy turboprops, you would undoubtedly be aware that idle thrust in flight (except during the landing maneuver) was definately not recommended, due in some engines to undesirable effects with the propellor reduction gear, with direct drive engines...for example RR Dart series.


My question is directed at those that actually have operated the Fokker 50...

[RatherBeFlying]

411A, I do not recall any cautions against idle selection in the Air Canada Viscount manual (RR Dart powered).

Except that the descent rate would approximate that of a brick

[xyz_pilot]

For info

On the F50 there is no restriction on the use of flight idle in the air.

The pw's dont have the Darts G/Box prob.

[JW411]

I spent ten years of my life being dragged through the skies by 4 RR Darts and I don't remember there being any problem about coming right back to the FFPS (flight fine pitch stop) apart from the rate of descent that this would cause. (I seem to remember that we would have between 200 and 240 torque on an average approach).

What you absolutely had to remember was that the ground fine pitch stop had to be engaged after landing before opening the throttles again otherwise all four engines would melt down very, very quickly!

[411A]

xyz_pilot.
Thank you.

JW411,

The FH227B flight operating manual (as well as some models of the Fokker F.27 contained a restriction on using flight idle due to rapid wear to planetary reduction gearing in the engine. In addition, the F.27 Mark 400 contained a restriction for engine ops between 12,500 and 14,000 rpm due to undesirable airframe vibration.

All of these models were Dart 7 powered.

Considering the falling brick scenario mentioned with regard to the 'ole Dart engine when in flight idle...and considering further that the F.50 did just that, made like a falling brick after flight idle was selected, perhaps a restriction in the AFM would be a good idea.
If a turbine engine enters a sub-idle state, or propellor pitch stops fail to work as advertised, acceleration might indeed prove difficult.