Flash Airlines B737 Crash in Egypt

[slipper 1]

Well said farty flaps! Will probably blame their instructors for teaching them the wrong things. I was chastised once out there for marking a students paper and only giving him 45% (which is what he acheived). I was brought before the C/O to explain why I had only taught the student 45% of the course material !! A law unto themselves.

[BOAC]

It appears the pdf report is 431 pages long which accounts for the delay in download and the speed of 747focal

[cringe]

CVR transcript (in English), as published in Le Figaro today:

http://www.lefigaro.fr/france/20041111.FIG0368.html

French BEA made an animation of the flight trajectory:

http://www.bea-fr.org/francais/actua...arm/video2.htm

[RatherBeFlying]

The CVR and BEA animation remind me of a simulator crash I was in. The LHS allowed the a/c to roll past 90 degrees at 16000 and ignored the increasingly frantic exhortations from the RHS (me) to level the wings.

The white on black horizon did not help, but my remaining impression is that the LHS brain crashed well before the a/c.

[blackmail]

dear fellow pilots,

having finally some info about what happened in that cockpit through voice recorder transcripts & flt data recorder analysis, i wonder why the egyptian & french authorities needed so long to come up with a preliminary accident report, containing hundreds of pages.

for me, as an experienced 737/3&400 pilot, this accident is a modelcase of back to &/or lack of basic flying skills & lack of understanding of interface/monitoring between crew & automatics (flightdirector & autopilot). absence of crm & oriental culture behavior (f/o in all his announcements called the captain who was the pilot flying :"sir"), prevented the first officer to take over control of the airplane before it was too late.

here a small resume of possible events:

it was 04:30local time, so fatigue is a factor.
an observer was on the jumpseat, is always a distracting factor.
ground ops were rushed: if any one can do the cockpit setup/briefing even if it is standard & god willing & ask for the before start checklist in less than 2 minutes : let us know.
now the take off: normal sequence except on the flight data recorder: toga on for 2sec's then off?? problem with auto throttle?
most of the time we forget to arm a/t before pushing toga switches on the thrustlevers( is not on the boeing before t/o cklist), sometimes it just kicks off at toga push with red flashing of a/t annunciator, after all could be an electronic glitch, reengaging a/t & try again mostly solves the problem & if that doesn't work we can always manually push the thrustlevers to the proper n1 target(basic stuff we all tend to forget, ok maybe not all, but still. ... )
normal fma mode annunciator on top of eadi's then would show from left to right: n1/then thr hold at +/- 80kts, toga, blank,fd,provided the fd switches were on as the case seem to be.
take off sequence seemed then normal & at 440ft the captain asked normally for hdg select, fd command bar would then follow setting of hdg bug on ehsi. now the sequence of events is about to start : capt ask "level change" which is executed by the f/o, fma then should show always from left to right : n1,mcp spd,hdg sel,fd. the a/t should then reduce to climbthrust to hold the salmonspeedbug which would have then synchronised with present speed circa v2+20. here F/o announces : n1arm,mcp spd,hdg sel,fd which is correct except for the n1/arm.it's either n1 or arm but not both. another scenario could have been t/off with a/t off, see above toga on for 2" then off.i think this meant a/t on for 2 " then off, the first lh fma annunciator case remaining blank troughout the take off.
then comes the call by the f/o : "1000ft"
normally the pilot flying(here the capt) should now ask for "speedbug 210/220 ", accelerate clean up & folow std climb procedures. but he ask for a/p on, which is still ok, but normally on 737 the pf engages his a/p himself, controlwheelforces etc.
and here it starts : probably because the a/p engaged in cws roll only, removing the vertical hdg command bar from the eadi, upset the pf which was expecting the a/p to come on & follow fd commands, a not uncommon annoying feature of this a/p, still about glitches, fd bars not synchronised at a/p engagement etc.
at that moment simple corrective action is to push again hdg sel push button & check correct fma annunciator, if ok, pf now set mcp speed 210/220, clean up & back to normal business.
what actually happened was that the autopilot was disconnected after 4 sec's,you hear the cavalry charge on the voice recorder, confirmed by the flightdata recordings : this is still ok but for then someone has to manually fly the aircraft & if the captain who is still pf thinks the autopilot is still on & behaving strangely, switch it off again! & take over manually & the f/o as pnf who monitors & correctly announces several times the degrading flightpath into a spiral dive : "overbank" ... ... "overbank" should have taken over from the captain after the second warning & seeing no corrective action from the lhs where obviously the brain had already crashed before the airplane did as stated in a post before. but lack of crm & cultural behavior prevented him to do so. i even don't want to mention upset recovery techniques which could still have saved the day.
and so an airplane came down with nobody flying the airplane & the captain still trying to reengage the autopilot with 110°bank angle & about 30°pitch down. that the observer stated"reduce power, reduce power" which was executed by the captain was by then irrelevant.
it is just plain enraging that 140 persons + crewmembers had to pay the price with their lives for such blatant amateurism.
but our industry is in such a devastated state for a zillion of reasons, that it will happen again & again.
i apologise for the last paragraph as i have no intention to offense anyone.

[blackmail]

dear fellow pilots,

referring to my previous post, when i say "experienced 737 pilot", i mean no arrogancy here as i learn every day from mistakes made by me & others, stay humble as the more you learn the more you realize the fact that you still know nothing.
i will never say : "this will not happen to me"
"never say never etc."

corrective action for mishaps as in sharm is :training, training. ... ... ... & training. but it all boils down to money, money. ... ... ... & money.

blame game is nothing. understanding why & how it happened so that we can device & implement corrective actions should be the name of the game.

safety used to be paramount some time(years) ago. today, safety is a liability. what's written on paper & what happens in reality are lightyears apart & it's in the wrong direction.

i hope, one day we will know exactly what happened, even that i understand that the truth will be very difficult to admit for the egyptian authorities, but so be it.

[flash8]

Do I detect a tad of bias? Citing "absence of crm & oriental culture behavior" etc? Implying these go together?

I'm fed up of the suggestions that are made when a crew of non-euro/non-white descent is involved in a fatal accident ... that somehow they are to blame/CRM is non-existent.

Viva la France!

[blackmail]

flash 8 & other fellow pilots,

latest news from paris: a slat nr1 staying in "ext" during flap retraction( indication confirmed by the flightdata recorder) may have compounded the problems of engaging the autopilot & may explain the right bank tendency of the airplane. it does not explain why the crew does not take over manual control when the autopilot is disconnected, but instead tries over & over again to find a solution by attempting to reengage the autopilot to no avail. sorry for flash8, but this is certainly not crm behavior as we understand it. crm= crew ressource management or cockpit ressource management as you like it or 1+1=3, here 1+1=0. nobody is flying the aircraft. & no bias whatsoever, but tell me what prevented the f/o to take control after 2 warnings of "overbank" were unheeded by the captain except a possible cultural barrier &/or a lack of experience on the plane ( both capt & f/o had 715 hrs together on the 737)?

for info this slat problem was known before departure as evidenced by discussions in the cockpit cfr voice transcripts by the captain & a technician.

the french & egyptian authorities are trying to hide the truth by publishing a "preliminary" report of over 435 pages plus or minus a few, 95% irrelevant,uncomprehensible to the general public, whereas the causes & the clues of what really happened could be summarized in about 20 pages. if my memory is correct the essentials are to be found in page 192,193.

and flash8, don't say viva la france: i am not french, but i agree that french authorities have a great part of responsibility in this tragedy by allowing this flight to have taken place in the first place & if you are fed up i feel sorry for you.

[KATLPAX]

What is wrong with commenting upon the lack of CRM and cultural behaviour when this is known to be a real factor in a number of accidents over the years in many non western cultures? So, yes absolutely the two do go together as the combination has shown to be a major factor in past accidents and should be considered especially in light of the information available.

What gets me is the fear of being politcally incorrect and not asking questions or commenting on issues that could have a positive impact on future accidents. The comments above on this are perfectly fair in light of the information currently available on the accident in question.

[Empty Cruise]

Surely, this kind of problem cannot be attributed to lack of type experience. It can have been a contributing factor to the initial a/p confusion, but it's definitely not explaining how the a/c ended up at +110 deg./-30 deg.? Put any student with 250 hrs in the sim, induce a roll of 45 deg. while on a/p and 75% will do something about it, a/p or not (the good ones would even remember to disconnect the a/p while stabilising the aircraft)

Training, training, training, throw in sop, sop & sop, and finally add a bit of CRM, airmanship and proper rest periods - and we would probably still be one 73 up

Brgds,
Empty

[alf5071h]

KATLPAX there is nothing wrong with commenting upon the lack of CRM and cultural behaviour providing you keep an open mind to the fact that similar accidents happen in western cultures due to the same lack of CRM and similar cultural (national and operational) behaviours.

Blackmail poses a plausible scenario, but I would prefer to wait for the experts opinion. Particularly with respect to any control input after autopilot disconnect – who made them and why. Also, if the vertical gyros have been recovered what was their condition.

Training is a solution for problems that have already been defined; we do not know the specific problem that lead to this accident.
If the problem was lack of awareness of autopilot status then the training need could be to focus on an instrument scan – what is the aircraft doing.
If the problem was an error in the ADI then operators need to look very carefully at how to train crews to deal with misleading instrument indications; again an issue relating to instrument scan.

[blackmail]

alf5071h,

hello,

no vertical gyro's as such on the 733, two irs's ( inertial reference system), same kind of stuff that allowed appollo 9 lem moonlanding in 1969, neal amstrong you know: "it's a small step for man, a giant leap for mankind". lasergyros(no moving parts),just opposed polarized laserbeams measuring angular accelerations & accelerometers which after integration gives speed & which after further integration gives distance, then triangular calculations in a computor to give position, attitude, hdg, speed , true winds, groundspeed etc. remember : on a 73 your only back up for these marvels are the sby compass & the sby attitude indicator, thanks to god(boeing)

[hobie]

The Animation link posted by Cringe above and produced by the French BEA is certainly a very sobering piece of evidence and well worth viewing

link is shown on Cringes post

[alf5071h]

Excuse my old terminology Blackmail, but the issue is to gain knowledge of what was displayed on the “EFIS / ADIs / artificial horizon”. With the particular equipment fit it appears most unlikely that anyone will know what the crew saw, even with your exotic description of an inertial platform. Another argument for a video in the flight deck.

[blackmail]

hello everyone,

cfr the slat nr1 remaining in "ext" position at flap retraction,
if this problem was known prior to departure, common sense would demand some kind of troubleshooting on the ground by maintenance (there was a technician available albeit with unknown qualification),to check if the problem was real (slat nr1 remaining in ext position) when all other slats & le flaps would be retracted, in this case definitely a no-go situation. or if the problem was a wrong indication on the overhead le devices panel, in which case a departure as per mel would be possible.
but, seen the rush for cockpit setup & checklist (less than 2 minutes), this seems whishfull thinking.
but anyway if a takeoff was made, elementary thinking would anticipate(another crm ref), a rolling moment to the right at flap retraction. maybe the captain at first (wrongly)thought the autopilot would do a better job for counteracting this previsible rolling motion? & hence the multiple a/p engagement attempts?we might never know. or maybe the whole thing was already forgotten when reaching flap retraction altitude? the time frame remaining to then address the problem was about 20 sec's

dear alf5071h,

please no video in the cockpits! if it will, these recordings will inevitably fall in the wrong hands & what about the feelings of the next of kin who will see over & over the last moments of their love ones on tv, assorted with the inevitable crap comments of those sensational thirsty journalists/commentators?don't expect any ethics here!
the flightdata recorder has all this information anyway.

[aerolearner]

Excuse my old terminology Blackmail, but the issue is to gain knowledge of what was displayed on the “EFIS / ADIs / artificial horizon”. With the particular equipment fit it appears most unlikely that anyone will know what the crew saw, even with your exotic description of an inertial platform. Another argument for a video in the flight deck.

What follows is just uninformed guesswork.
I noticed that three columns in the tables beginning at page 227 of the .pdf file are labeled PITCH ANGLE EFIS / ROLL ANGLE EFIS / MAGNETIC HEADING EFIS. Does this mean that the DFDR actually records the data available to the crew through the EFIS?

[golfyankeesierra]

a/t disconnect

Blackmail,

now the take off: normal sequence except on the flight data recorder: toga on for 2sec's then off?? problem with auto throttle?

Maybe it was the "old type" autothrottle computer that doesn't allow controlwheel input (aileron in the wind) during to/ga selection , the switch will drop off. (Although 2 sec's is a bit late for it to drop off).

[Burger Thing]

Hey Blackmail,

when I read through the descript of the Voice recorder, I was thinking pretty much the same as you. It is really hard to understand, that the FO just sits there and shouts: Overbank! Instead of grabbing the controls.

In fact the accidents reminds me a bit of the B757 which plunged into the sea of the Dom. Republic a few years ago, operated by a turkish crew.

I might create a stir here, but I dare to say, that if this aircraft was flown by an crew from maybe a different part of the world, which practises hand flying once in a while with AutoPilot off and the FO wouldn't rather sxxt into his pants instead of taking over control, nothing would have happend, but only an entry into the tech log, after landing. So many people dead. Woman, children.

It seems that in some part of the world the autopilot is regardes as the magic wichcraft box.: Turn it on, and the aircraft will fly itself out of every ****ty situation. Sorry, Pals! It ain't work that way.

[Casper]

Very similar to the GA 072 prang (A320). Except for the phase of flight, many characteristics are similar.

[Stripes]

Basic airmanship/CRM or just plain bloody common sense. One pilot flies the aircraft and the other's primary job is to MONITOR that guy's flying - irrespective of the phase of flight or what problems may have occurred.

The lack of action from the RHS could be due to any number of reasons but I will never allow anyone to fly me into the ground without trying to do something about it. Unfortunately for a lot of people this F/O did just that. The investigators really need to examine the training methods and attitudes of this company in minute detail to see exactly what they do. A lot of people dead for no good reason.