Flash Airlines B737 Crash in Egypt

[Flight Safety]

Some interesting news links

Some interesting news links regarding this accident.

Jan 31st

Text from the Jan 31st article...

Plane rudder 'not cause' of Egypt crash

PARIS, Jan 31 (AFP) - The rudder on an Egyptian charter plane was not the cause of its fatal crash earlier this month, a top French aviation official said Saturday.

The comment by Paul-Louis Arslanian, head of the French office of civil aviation investigations and analysis (BEA), followed news that the Flash Airlines flight which careened on January 3 into the Red Sea, killing all 148 aboard, had at one point made an unexpected turn off its original flight path.

Jan 21st

Jan 20th

[Pax Vobiscum]

BBC R4 'File on 4' on air safety

Very good (to my interested layman's ear) programme on Radio 4 yesterday evening. It discussed the Flash airlines crash, where the airline had previously been banned in Switzerland, the Yak-42 crash that killed 62 Spanish soldiers on a plane that had been banned from similar charters by several Scandinavian countries, and the KAL 747 crash at Stansted - all done in a serious, non-hysterical way. There was also an interview with the Aviation Minister (Tony McNulty).

The web site is here and you can hear the programme again at 5pm on Sunday (8th Feb) or on the web here (at least for the next week).

[Rockhound]

Pax V,
Thanks for posting the link to that Radio 4 programme on air safety, which I (another interested layman) also found very interesting and informative. Parenthetically, I must say that Mr McNulty is a bit of a slippery character; little wonder he ended up a politician.
However, IMHO the Korean Air freighter accident at Stansted in 1999 was not presented entirely fairly. Certainly the branding of KAL pilots as incompetent by a layman totally unqualified to comment should not have been broadcast. The crew of that KAL 747F was woefully short on CRM but the accident occurred (as most do) because of a series of circumstances coming together, involving not just pilot error, lack of CRM, and bad weather but also a glitch in instrument maintenance and repair on the ground at Stansted. All of this is documented in the AAIB Accident Report 3/2003, which, it looks to me, was not consulted by the producers of the radio programme. On the freighter's previous leg, a different KAL crew had encountered the same faulty instrument but resolved the problem routinely (but in daylight, in good weather).
As well, by the time of the Stansted accident, Korean Air was already two years into a massive overhaul of operational safety procedures (initiated after the Guam accident in 1997). As a matter of fact, KAL had begun CRM training based on an American model back in 1986. Obviously, the benefits of such training, as the AAIB report pointed out, sometimes take too long to take effect.
Rockhound

[atakacs]

New ?!

Anything happening ?

Just wondering: was there any further debris recovery (engines... ?)

[Man Flex]

Interesting article in 'Flight' this week regarding this incident.

It suggests from the onboard recording devices and the ground radar trace that the aircraft started to depart from its planned track at about 2000'. The aircraft then reached an extreme angle of bank at about 5000' before diving into the sea. There was no panic on the flight deck but the crew were clearly puzzled.

There has already been suggestions on this thread that some sort of electrical problem occurred leading to a loss of orientation and control. I would suggest from this latest report that this seems to be the most likely cause of this disaster.

[RASTAMIKE]

Pilot error?

Just heard quickly on the french radio (RFI): it seems that the crew had the impression that the AP was engaged but it was not (technical disfunction?). Spatial disorientation followed and could not recover from a dive...

this info leaked from the French investigation office, not confirmed by the Egyptian authorities!

Ref (in french):

http://www.rfi.fr/actuchaude/DET_tit...m1=1&m2=2&m3=3

[mullers]

Technical and human factors in Flash Airlines crash: reports
Kieran Daly, London (03Mar04, 09:41 GMT, 130 words)


French media reports say investigators have determined that the fatal loss of the Flash Airlines Boeing 737-300 at Sharm-el-Sheikh, Egypt in January occurred when the crew failed to recognise that the autopilot had not engaged as commanded after take-off.

The detailed reports describe the aircraft gently banking left as it departed at night-time over the Red Sea while the crew calmly tried to understand what was happening – apparently realising only in the last few seconds the true situation.

The aircraft finally rolled perpendicular to the horizon before crashing into the sea. All 148 occupants, 135 of whom were French, died.

Both the flight data recorder and cockpit voice recorder were recovered and France’s investigation body, the BEA, is expected to release an interim report shortly – possibly as soon as today.


Source: Air Transport Intelligence news

[Man Flex]

This is almost unbelieveable - nobody noticed that the aircraft was increasing bank and nobody did anything to react to it!

But then again a L10-11 crashed into the Florida everglades some years back and three of them failed to notice that the aircraft was descending.

Too many heads down and not enough heads up me wonders.

[Beanbag]

Dark, over water ... not so unbelievable. If anything, too much heads up?

[Moonraker One]

Fatigue could have also played a part in this accident.

[TheShadow]

Autopilot or Flight Instrument Failure

Perhaps someone smarter than I (and there must be literally scores of you out there) explain how the DFDR and CVR interpreters might have lamped upon it being an auto-pilot failure to engage rather than an across-the-board CRT failure or a singular ADI failure.

What would or could have been the confirmatory clue (or did they not consider a flawed attitude instrument as a possibility?). If the autopilot didn't engage, is a classic 737 going to go clack-clack?

In any configuration (in a non-upgraded classic 737) is the autopilot's vertical gyro going to be the same source of attitude info as used by one of the pilot's ADI's?

Don't know, just asking.

[Capt.KAOS]

According Le Figaro apparently the AP wasn't functioning and the a/c practically was going it's own way (En réalité, à cet instant-là, le pilote automatique ne s'est pas mis en service. Plus grave, l'équipage ne s'en est pas aperçu. Les gouvernes sont libres.) Captain and F/O knew there was something wrong but didn't know what, assuming it was on AP.

Seems the Capt had (only?) 500 and F/O 250 flight hours on a B737.

[despegue]

On B737,and on most other EFIS equipped airliners, a green CMD annunciation will shown if the A/P is engaged. But it is clear that basic airmanship requires a constant evaluation/follow-up of the automatic systems, especially on B737 which is known for it's weak A/P and F/D systems.

[Flight Safety]

These are google English translations of Frence reports on Yahoo.

Wednesday March 3, 2004, 9h18

Charm el-Sheik: the crew thought of having engaged the autopilot

PARIS (AFP) - the crew of the Boeing of the Airlines Flash, which was damaged at sea Rouge on January 3, making to 148 victims whose 134 French, believed, wrongly, to have engaged automatic piloting, affirms Wednesday the Barber.

"the crew believed to have brought into service the autopilot. In fact, this last never engaged. And the pilots probably never succeeded in identifying this failure ", writes the daily newspaper, while being based on the analysis of the block boxes.

Questioned by the AFP, the Office of investigations and analyses (BEA) for the safety of the civil aviation did not wish to make comment but indicated that it would publish an official statement in middle of morning.

An informed source underlined however that the survey, carried out by the Egyptian authorities, was not finished and that, at this stage, information was to be taken with precaution.

The crash of the Boeing, with broad of Charm el-Sheik (Egypt), is with "an error of human, consecutive with a technical anomaly", affirms the Barber.

"Delivered to itself, the Boeing 737 left gradually in turn, then has piqué towards the sea", notes the newspaper.

"Until the end, the two pilots thought of being able to control the situation. No exclamation of discouragement or even of astonishment resounded in the cockpit ", according to the daily newspaper, which specifies that "right before falling into the Red Sea (...) they try an ultimate operation of recovery but the plane is too low".

"Our role is of knowing why the crew arrived at such a situation", explains Paul-Louis Arslanian, director of the BEA for the safety of the civil aviation, quoted by the Barber. "the investigation continues and all the means are good", adds it.

link

Then later, the BEA denies this, and says that BEA has yet to determine a cause.

Wednesday March 3, 2004, 9h52

Catastrophe of Charm el-Sheik: "no precise element" new, according to the BEA

PARIS (AFP) - the Office investigations and analyses for the safety of the civil aviation (BEA) estimated Wednesday that no element, at this stage, made it possible to draw the conclusions on the origin of the accident on January 3 of the Boeing of the Airlines Flash in Charm el-Sheik.

"No precise element to date makes it possible to explain what really occurred to Charm el-Sheik", according to information collected Wednesday at the BEA in Paris, following an article published the same day by the Barber on the origin of the catastrophe.

According to the daily newspaper, the crew of the Boeing of the Airlines Flash which was damaged at sea Rouge on January 3, making to 148 victims whose 134 French, wrongly believed to have engaged automatic piloting.

Questioned, the BEA, which should publish an official statement Wednesday in the course of the day, did not wish to make of another comment. It simply indicated that "as soon as there is information, they will be made public by the Egyptian authorities" which direct the investigation on the spot. According to BEA'S, "work continues" on the spot, and "of the meetings currently take place in Cairo between the teams Egyptian woman, Frenchwoman (BEA) and American (NTSB) which take part in the investigation".

An informed source had stated previously that the information of press was to be taken with precaution.

According to the Barber, the crash is due to "a human, consecutive error with a technical anomaly". "Delivered to itself, the Boeing 737 left gradually in turn, then has piqué towards the sea", specifies the newspaper adding that "until the end, the two pilots thought of being able to control the situation".

link

Then later...

Wednesday March 3, 2004, 19h29

Catastrophe of Charm el-Sheik: denial of the BEA on the error of the crew

PARIS (AFP) - the Office of investigations and analyses for the safety of the civil aviation (BEA) contradicted Wednesday the assertion according to which the crew of the Boeing of the Egyptian company Flash Airlines would have believed itself in automatic piloting at the time of the accident from January 3 in Charm el-Sheik.

"the assertion which the crew would have believed in automatic piloting is stripped of any base", indicated the BEA in an official statement.

The elements of the investigation in progress "do not make it possible yet to include/understand and explain the sequence of the accident, the investigators get busy there but, in the current state, any extrapolation of the described facts would be only speculation", according to BEA'S.

According to the French daily newspaper the Barber of Wednesday, the crew of the Boeing of the Airlines Flash which was damaged at sea Rouge on January 3, making to 148 victims whose 134 French, wrongly believed to have engaged automatic piloting.

The BEA, which takes part in the investigation with the Egyptians, pointed out the first conclusions of work thus undertaken. It stressed that it was possible "d?éliminer any rupture in flight d?une part of structure of l?avion, any dysfunction of the engines or the rudder, any act of ill will or attack".

But, "nothing in l?examen files l?équipage, of preparation of the flight or d?entretien of l?avion n?a highlighted which explains l?accident", it added.

Work d?enquête continuous and of new meetings of work are in hand in Cairo, indicated the BEA, specifying that it "was not excluded that these meetings are prolonged by joint work with the flight simulator".

The two block boxes of the Egyptian chartered plane were recovered by the French robot Scorpio and were entrusted to the Egyptian board of inquiry, which works with experts of the BEA and an observer of Boeing.

link

Stay tuned folks. The BEA should have released an investigation update yesterday.

[chrisN]

Not to anticipate the investigation results, but hypothetically for any aircraft; could the (prohibited but it happens) use of mobile phones or other electronic devices by passengers cause an A/P to fail to engage when commanded, or cause the A/P to disengage?

Chris N.

[Wizofoz]

chrisN,

I don't know but it is probably more simple than that. The 737 autopilot will not engage if there is any pressure being applied to the control column at the time. If you try to engage it in a turn it takes a bit of practice to centralise the column, then engage the A/P.

Older 737-300s had very positive "Paddle" switches which had a magnetic lock when engaged. If they DIDN"T engage they very positivley sprang back to the off position, so you knew imediatley it hadn't gone in. Later ones have a button of the same type as the other MCP switches. To verify the A/P has engaged you MUST check the Mode Annuncitor Panel.

It wouldn't be hard for a (tired?) crew to push the button while some control input was in, believe the A/P was engaged, and miss the lack of the little green "CMD" on the ADI.

That being said, then allowing the aircraft to depart controlled flight and not be able to recover shows an over relience on automation and lack of basic skills, something whch I believe is becoming prevelant throughout the industry.

[Cejkovice]

The Egyptian Authorities are now saying the pilot knew there was something wrong from the time he engaged A/P, FO dissengaged it after 4 secs claiming a/c not handling correctly. From earlier reports though it seemed the pilots were unaware right until near the end??? Hopefully we're not in a situation like the Egypt Air crash where two sides disargee as that will not improve safety for future flights.


Source: Agence France Presse
The pilot of the Egyptian airliner which crashed in January engaged the autopilot while making a turn, shortly before its nosedive into the Red Sea, the chief investigator said yesterday. He told a press conference that, according to the flight data and voice cockpit recorders of the Flash Airlines Boeing 737, the auto-pilot worked for four seconds and then the pilot asked the co-pilot to switch it off.

"While the autopilot was on, we hear the pilot saying he spotted something wrong," said the investigator, without specifying whether the hitch was related to the autopilot. "Seconds later, the co-pilot says the plane is not responding as it should. We hear that the plane is going to the right, and it kept going to the right," he said.

He added that the investigators are now trying to determine what happened between the moment when the autopilot was engaged and the crash and he underlined that the on and off switching of the autopilot "is not abnormal and does not lead to a dangerous position."

[Wizofoz]

Interesting...

But if the A/P WAS engaged and the F/O DID disengage it, it would have been on the FDR trace, and the disconnect warning (about the loudest warning in the cockpit) would have been on the CVR tape.

Just speculation, but if the Captain THOUGHT he'd engaged the A/P, but it hadn't gone in, he might have interpretted the flight path as a mal-funtioning A/P.

Hope the investigation makes it all clear.

[Kaptin M]

Any crew who disengaged an autopilot because they suspected it was malfunctioning, is going to be all the more alert when they next engage it.

This is one of the (very) few times that Wizofoz and I appear to be in agreement

...shows an over relience on automation and lack of basic skills, something whch I believe is becoming prevelant throughout the industry.

Personally, I find it very hard to believe that any crew would sit and watch their aircraft enter into an uncommanded turn, let alone start descending during the post take-off phase of flight, regardless of experience on type.
The scenario offered by the authorities so far might seem feasible to those with little or no flying experience, or to pilots with limited night visual flight. It certainly does NOT ring true with pilots who fly jets as their profession!

[BigHitDH]

Does anyone know if this aircraft was equipped with a GPWS system?

What about about a gyro faliure, I seem to recall that happening on another 737 with the same result while both horizons were on the same gyro.