Flash Airlines B737 Crash in Egypt
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The Fitting Analysis (that fits the facts)
Casper
There was one. See Factual or link at Belgique's post above.
Midland63
Not necessarily "wrong" but suggest you read right through the excellent, clear and precise analysis at Belgique's link above (previous page).
I'm unaware of any slat problem??
Midland63
Please tell me if I'm wrong.
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I don't see any "Human factors" connection with Concorde at all....
As I am sure you are both acquainted (as professional pilots) with engine failure SOP's on 3 crew aircraft you will appreciate that the Captain and Flight Engineer must consult on critical configuration changes to the aircraft after such an event. Such changes are actioned by the FE and monitored by the Captain.
Nowhere in the various operating concepts of 3 crew operations is it advocated that the flight engineer, without monitoring or prompting, shuts down an engine before the aircraft becomes airborne. This was the case in AF4590 between 151 and 188 knots before the a/c left the ground (see report).
The damage to the wing was indeed caused by the failure of a mainwheel tyre precipitated (we are told) by trampling metallic runway debris. Occasionally in other aircraft tyre failure causes flap damage or even a slight fuel leak, but to lose an engine(s) was an unprecedented design shortcoming. It is worthy of note that British Airways had already adopted undercarriage modifications to mitigate the result of a tyre bursting. In any case the loss of an engine, even in Concorde is generally accepted as survivable.
Had the crew continued the take-off (without FE's intervention) with two damaged engines on the LHS and sat on their hands it is a possibility that:
a) The fire would have abated when the damaged fuel cell emptied, as was in evidence shortly before impact.
b) Sufficient Green Hydraulic pressure MAY have been available to raise the gear and permit them to accelerate to a safe speed. As it transpired, the moment they were unable to raise the gear with No.2 engine already shutdown by the FE and No.1 winding down through failure, their fate was sealed. The inability to accelerate to a safe speed was the direct cause of the crash.
Is there another airline that permits FE's to shut down engines during the take-off roll without reference to the other crew? Was this AF SOP or just a misguided action? I suspect we may never find out... Not from AF anyway.
The PR fallout from the deep landing & overrun crash in YYZ has been contained through the efforts of AF to highlight the sterling efforts of the crew in evacuating the aircraft in short time. This has also been echoed (I am ashamed to say) by the French pilots union keen to turn a mishandled deep landing and overrun into a PR success.
Midland63, et al, the difficulty with accident investigation involving human behaviour is that there are few clear-cut, good/bad causes. In most accidents, it is the combination of factors and circumstances that are the ‘cause’ i.e. if any one of them was removed then the accident may not have occurred, but even then it is unlikely that we can be sure.
National accident investigators are bound by ICAO guidelines that require focus on the facts, and even when human issues are investigated, then only a few aspects may be selected as contributing ‘causes’. Several posts and linked material follow this restricted line of thought.
Re autopilot engagement, this is not necessarily a good or bad thing, what has to be judged is was engagement allowed in the circumstances, was it advisable, and what the crew’s reasoning for this was. It is unlikely that these can be answered precisely on the information available without making assumptions (which are normally avoided in formal investigations).
What was the effect of the Captains subconscious recall of previous instrument flying? This has to be considered in context. It is feasible for pilots’ to revert to previous habits especially under stress (first learnt, best remembered), but the level of stress can only be inferred, as could the likelihood of a particular person remembering and reverting – behaviour / change of habit.
What was the role of the asymmetric slat retraction? Posts relating to a previous 737 incident show how misleading unbalanced lateral control forces can be, a pilot can easily suffer a ‘force’ illusion, expecting a normal situation where zero force equates to the controls being in the centre. Whilst this situation is recoverable, it depends on the crew’s situation awareness, the detection of the cause, and then taking action in an appropriate time scale. Combine these issues with instrument flying, darkness, early start time, fatigue, etc, etc, and then all that the investigators are left with is supposition.
Error is something that describes the outcome of behaviour. It can only be attributed after the facts are known, thus it is not always helpful to say that a pilot made an error, whereas the identification of any error provoking circumstances or human behaviour could provide valuable lessons to be learnt.
What the industry requires is an investigation report of the facts and circumstances, which enable an opportunity for us be more speculative in seeking and applying safety lessons. An essential ingredient of this is for us to clearly state the assumptions being made and the context they are being used in. Thus for “PNF (the F/O) recognised PF's error”, this is an assumption as it would be difficult for the PNF to detect any thinking error involving the Captain’s interpretation of the instruments, or the lateral control feel without being hands on himself.
Failure to state the assumptions and circumstances usually results in the conclusion that CRM failed, yet in many instances it is the individual human weaknesses or the organisational circumstances that are the initiating contributory factors.
CRM failed? Probably, but was this the interpersonal aspects or the individuals’ thinking and understanding, or organisational and training issues that dominated the probable causes? Probably ‘all of the above’.
National accident investigators are bound by ICAO guidelines that require focus on the facts, and even when human issues are investigated, then only a few aspects may be selected as contributing ‘causes’. Several posts and linked material follow this restricted line of thought.
Re autopilot engagement, this is not necessarily a good or bad thing, what has to be judged is was engagement allowed in the circumstances, was it advisable, and what the crew’s reasoning for this was. It is unlikely that these can be answered precisely on the information available without making assumptions (which are normally avoided in formal investigations).
What was the effect of the Captains subconscious recall of previous instrument flying? This has to be considered in context. It is feasible for pilots’ to revert to previous habits especially under stress (first learnt, best remembered), but the level of stress can only be inferred, as could the likelihood of a particular person remembering and reverting – behaviour / change of habit.
What was the role of the asymmetric slat retraction? Posts relating to a previous 737 incident show how misleading unbalanced lateral control forces can be, a pilot can easily suffer a ‘force’ illusion, expecting a normal situation where zero force equates to the controls being in the centre. Whilst this situation is recoverable, it depends on the crew’s situation awareness, the detection of the cause, and then taking action in an appropriate time scale. Combine these issues with instrument flying, darkness, early start time, fatigue, etc, etc, and then all that the investigators are left with is supposition.
Error is something that describes the outcome of behaviour. It can only be attributed after the facts are known, thus it is not always helpful to say that a pilot made an error, whereas the identification of any error provoking circumstances or human behaviour could provide valuable lessons to be learnt.
What the industry requires is an investigation report of the facts and circumstances, which enable an opportunity for us be more speculative in seeking and applying safety lessons. An essential ingredient of this is for us to clearly state the assumptions being made and the context they are being used in. Thus for “PNF (the F/O) recognised PF's error”, this is an assumption as it would be difficult for the PNF to detect any thinking error involving the Captain’s interpretation of the instruments, or the lateral control feel without being hands on himself.
Failure to state the assumptions and circumstances usually results in the conclusion that CRM failed, yet in many instances it is the individual human weaknesses or the organisational circumstances that are the initiating contributory factors.
CRM failed? Probably, but was this the interpersonal aspects or the individuals’ thinking and understanding, or organisational and training issues that dominated the probable causes? Probably ‘all of the above’.
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Alf5071h... You make some very valid points about the human factors of this accident. The Egyptian investigators are cognoscente that the eyes of the world are upon them and they must come up with a clean and credible report in this investigation.
There are some very salient but subtle points to be drawn from their report, and (to be very controversial) I am going to assume that the aircraft was serviceable in all regards as it left the runway....
1) The Captain's military/civil flying career comprised time on the Gomhoria light prop trainer, DHC-5 Buffalo, th C130 Hercules and the ATR42. It seems he had no exposure in his career to 'Upside-Down' Russian artificial horizons, so to suggest that he might have 'reverted to previous type' and inadvertently overbanked would be invalid.
2) The Captain had NO jet transport experience prior to his transition onto the 737 in May 2003. He had therefore commanded a 737 for only 7 months prior to the accident. We could presume he had previous military command experience from the C130 et al, but his civil command experience would have been limited to the ATR. So here we have a pilot whose first Jet public transport job is as a Captain ..... having never flown a turbine aircraft before. Indeed it seems that the TOTAL 737/Jet Transport time on the flight deck was only 716 hours (Capt-474 FO-242).
3) The crew had operated 7:15 block time in the last 24 although we are not told whether the accident flight formed part of the same duty. Given 4 sectors for the duty period with 60 minutes t/r time would suggest an FDP of at least 11:15. If this was the same duty or a indeed a subsequent one reporting at 0100 local, I think we can safely assume that they were both quite tired.
4) After rotation from 22L at SSH you will see the lights of Namaa Bay directly ahead, but as they turned left to pickup the 330 radial out of the SKH NDB they were turning over a totally dark seascape on a night with no moon.
5) At no stage after rotate did anyone verbalise a system or instrumentation failure. Which means either there was not one, or it had already previously on the ground or it was not recognised at all in the air.
6) From the FDR and CVR data all appears well until the IAS reaches 190 kts (Flap 1 to Flaps up) where the AOB starts becoming abnormal. At this same time the #1 Slat fails to retract from the mid-position to up. As has been suggested above this asymmetry produced a reaction of incomprehension from the crew. Whilst this asymmetry of control was self-evident nobody recognised the cause. The Captain grappled with the sort of roll problem normally precipitated by an engine failure. Of the 3 dynamic forces yaw is by far the most disorientating and this would have been manifested to the PF in this 737 as a happy blend of all three.
7) The Captain recognised a problem and (correctly) attempts to unload himself by engaging the autopilot. Unfortunately without a trimmed a/c they struggle to engage or keep autoflight engaged and fuddle through the various un-intuitive modes and FMA annunciations on the 737, finally devoting their collective capacity to this one task. The collective preoccupation proves fatal.
Yes there are CRM issues here, a greater level of assertiveness of the P2 or indeed the J/s Observer would have almost certainly saved them. There may have also been contributory authority-gradient and cultural factors, but we will never know.
Most accidents with Human Factors involve a simple (non-critical) influence that takes one or more of the pilots outside their ability/comfort zone. I don't think this accident was any different.
There are some very salient but subtle points to be drawn from their report, and (to be very controversial) I am going to assume that the aircraft was serviceable in all regards as it left the runway....
1) The Captain's military/civil flying career comprised time on the Gomhoria light prop trainer, DHC-5 Buffalo, th C130 Hercules and the ATR42. It seems he had no exposure in his career to 'Upside-Down' Russian artificial horizons, so to suggest that he might have 'reverted to previous type' and inadvertently overbanked would be invalid.
2) The Captain had NO jet transport experience prior to his transition onto the 737 in May 2003. He had therefore commanded a 737 for only 7 months prior to the accident. We could presume he had previous military command experience from the C130 et al, but his civil command experience would have been limited to the ATR. So here we have a pilot whose first Jet public transport job is as a Captain ..... having never flown a turbine aircraft before. Indeed it seems that the TOTAL 737/Jet Transport time on the flight deck was only 716 hours (Capt-474 FO-242).
3) The crew had operated 7:15 block time in the last 24 although we are not told whether the accident flight formed part of the same duty. Given 4 sectors for the duty period with 60 minutes t/r time would suggest an FDP of at least 11:15. If this was the same duty or a indeed a subsequent one reporting at 0100 local, I think we can safely assume that they were both quite tired.
4) After rotation from 22L at SSH you will see the lights of Namaa Bay directly ahead, but as they turned left to pickup the 330 radial out of the SKH NDB they were turning over a totally dark seascape on a night with no moon.
5) At no stage after rotate did anyone verbalise a system or instrumentation failure. Which means either there was not one, or it had already previously on the ground or it was not recognised at all in the air.
6) From the FDR and CVR data all appears well until the IAS reaches 190 kts (Flap 1 to Flaps up) where the AOB starts becoming abnormal. At this same time the #1 Slat fails to retract from the mid-position to up. As has been suggested above this asymmetry produced a reaction of incomprehension from the crew. Whilst this asymmetry of control was self-evident nobody recognised the cause. The Captain grappled with the sort of roll problem normally precipitated by an engine failure. Of the 3 dynamic forces yaw is by far the most disorientating and this would have been manifested to the PF in this 737 as a happy blend of all three.
7) The Captain recognised a problem and (correctly) attempts to unload himself by engaging the autopilot. Unfortunately without a trimmed a/c they struggle to engage or keep autoflight engaged and fuddle through the various un-intuitive modes and FMA annunciations on the 737, finally devoting their collective capacity to this one task. The collective preoccupation proves fatal.
Yes there are CRM issues here, a greater level of assertiveness of the P2 or indeed the J/s Observer would have almost certainly saved them. There may have also been contributory authority-gradient and cultural factors, but we will never know.
Most accidents with Human Factors involve a simple (non-critical) influence that takes one or more of the pilots outside their ability/comfort zone. I don't think this accident was any different.
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An indication that the No. 1 slat stayed in the extended position during flap retraction (as confirmed by the flight data recorder) may have compounded the problems of engaging the autopilot and may explain the aircraft's persistent right banking.
---------------------------------------------------------------
Overtalk & Magplug,
I copied the above from a publication re the No 1 slat. Do you, however, have any references to this evidence as being supplied by the "official" FDR analysis (other than the above reference)? The CVR transcript (since removed from the ASN site) mentions other functions as confirmed by FDR analysis but does not mention any malfunction of the slat - which should not have been a showstopper in any event.
Thanks for the advice.
---------------------------------------------------------------
Overtalk & Magplug,
I copied the above from a publication re the No 1 slat. Do you, however, have any references to this evidence as being supplied by the "official" FDR analysis (other than the above reference)? The CVR transcript (since removed from the ASN site) mentions other functions as confirmed by FDR analysis but does not mention any malfunction of the slat - which should not have been a showstopper in any event.
Thanks for the advice.
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Casper,
The Egyptian Factual Report is published on the BEA website. It's a long read in the format required by ICAO. Page nos. refer to the PDF page not individual documents contained therein.
http://www.bea-fr.org/docspa/2004/su...-f040103pa.pdf
The FDR tabular data begins on page 97 at 02:34:50 however it is not until page 178 at time 02:43:38 just after selecting Flaps-Up at 190 kts that the problems begin. The previously steady left 20deg AOB climbing turn strangely stops on a heading of about 160deg despite the sustained and continued application of 20deg AOB. Thereafter the aircraft deviates from the expected flight path although on page 369 the report states that:
If you refer to page 192 you will find the beginning of the FDR discrete control positions. On page 195 you will see the moment when the Leading Edge Slats are commanded to retract at 02:43:27. The process is complete on all LED's by time 02:43:33 with the exception of LE Slat #1 which remains deployed in the mid position until the end of the data at 02:45:02.
The (expected) GPWS discretes for the Bank Angle, Too Low Terrain and Terrain-Terrain-Pull-Up are absent from the FDR data. It is possible this aircraft was not fitted with even rudimentary GPWS that might have saved them.
As you say the situation should not have been a showstopper. However yaw influences in the 737 are manifested in roll as opposed to the conventional Turn & Slip Ball flying off in one direction. The crew were tired and inexperienced, flying on a black night with no natural horizon. Given the circumstances it is hardly surprising that disorientation led to autopilot preoccupation and the fatal crash.
The Egyptian Factual Report is published on the BEA website. It's a long read in the format required by ICAO. Page nos. refer to the PDF page not individual documents contained therein.
http://www.bea-fr.org/docspa/2004/su...-f040103pa.pdf
The FDR tabular data begins on page 97 at 02:34:50 however it is not until page 178 at time 02:43:38 just after selecting Flaps-Up at 190 kts that the problems begin. The previously steady left 20deg AOB climbing turn strangely stops on a heading of about 160deg despite the sustained and continued application of 20deg AOB. Thereafter the aircraft deviates from the expected flight path although on page 369 the report states that:
...the extreme bank attitude that occurs towards the end of the flight is consistent with recorded motion of the ailerons.
The (expected) GPWS discretes for the Bank Angle, Too Low Terrain and Terrain-Terrain-Pull-Up are absent from the FDR data. It is possible this aircraft was not fitted with even rudimentary GPWS that might have saved them.
As you say the situation should not have been a showstopper. However yaw influences in the 737 are manifested in roll as opposed to the conventional Turn & Slip Ball flying off in one direction. The crew were tired and inexperienced, flying on a black night with no natural horizon. Given the circumstances it is hardly surprising that disorientation led to autopilot preoccupation and the fatal crash.
Last edited by Magplug; 7th Feb 2006 at 20:47.
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Thanks again for the info, Magplug. As you say, the holes of inexperience, tiredness, probable minimum training and the black hole effect all lined up nicely on the occasion.
Flap / slat abnormalities can still cause problems in the simulator for crews who are experienced, rested and expecting them!
Flap / slat abnormalities can still cause problems in the simulator for crews who are experienced, rested and expecting them!
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Oh..... and of course the [LE Flaps Transit] Amber warning would have remained illuminated on the centre instrument panel with the associated abnormal warning in the overhead expanded annunciator. Whilst this primary warning is in a conspicuous position it has no other attention-getting means such as an audio warning as this is not 'Boeing Philosophy'.
Unfortunately it appears none of the 3 pilots inexperienced pilots recognises & verbalises the warning. If they had..... reselecting the flaps back to 1 would have cleared the handling difficulties in seconds.
Unfortunately it appears none of the 3 pilots inexperienced pilots recognises & verbalises the warning. If they had..... reselecting the flaps back to 1 would have cleared the handling difficulties in seconds.
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How UNFlash is this?
The Egyptians back in character (I knew that they'd find something)
Egypt : Plane crash report delayed for 3rd time
February*21,*2006, 22 hours, 1 minute and 29 seconds ago.
By Andnetwork .com
An Egyptian committee investigating the crash of a passenger plane more than a year ago has delayed its announcement for the third time, saying it will release it on March 25.
The report was due to be announced in late February. The report has unmasked a technical fault in the rotation system of the plane, owned by the Flash Airlines, it was learnt.
The plane crashed into the Red Sea with 148 people on board shortly after take-off from Sharm el-Sheikh, Egypt, January 2005.
Source : Egyptian Gazzette
Egypt : Plane crash report delayed for 3rd time
February*21,*2006, 22 hours, 1 minute and 29 seconds ago.
By Andnetwork .com
An Egyptian committee investigating the crash of a passenger plane more than a year ago has delayed its announcement for the third time, saying it will release it on March 25.
The report was due to be announced in late February. The report has unmasked a technical fault in the rotation system of the plane, owned by the Flash Airlines, it was learnt.
The plane crashed into the Red Sea with 148 people on board shortly after take-off from Sharm el-Sheikh, Egypt, January 2005.
Source : Egyptian Gazzette
Pegase Driver
On another site the Egyptian CAA is quoted as having said that the report shows " shorcomings in the Auto-Pilot" and mentions " lack of time for pilot to correct them "
If this is indeed in the final report the reasons of the crash will then an auto pilot and too little time , fate in other words...
If this is indeed in the final report the reasons of the crash will then an auto pilot and too little time , fate in other words...
to quote from Rudyard Kipling.....
We can pull and haul and push and lift and drive,
We can print and plough and weave and heat and light,
We can run and race and swim and fly and dive,
We can see and hear and count and read and write!
But, remember, please, the Law by which we live,
We are not built to comprehend a lie,
We can neither love nor pity nor forgive.
If you make a slip in handling us you die!
Always apt... from "The Secret of the Machines" (from the introduction of "Destination Disaster").
We can pull and haul and push and lift and drive,
We can print and plough and weave and heat and light,
We can run and race and swim and fly and dive,
We can see and hear and count and read and write!
But, remember, please, the Law by which we live,
We are not built to comprehend a lie,
We can neither love nor pity nor forgive.
If you make a slip in handling us you die!
Always apt... from "The Secret of the Machines" (from the introduction of "Destination Disaster").
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It will be very sad indeed if the Egyptians bury the blame for this accident with some veiled reference to technical matters that the pilot was unable to counteract.
The cause of the accident is clear and 95% definitive:
1. One section of Leading Edge Slats failed to retract after take-off, leading to some handling difficulties, however those difficulties are within the capabilities of a below-average pilot.
2. This handling problem is superimposed a background of:
- an inadequately experienced flight crew,
- crew fatigue,
- the lack of visual horizon on the night,
- both pilots becoming preoccupied with attempting to engage the autopilot.......whilst the aircraft takes a random path through the sky.
Someone one said, If you lay enough traps in my path then I am certain to fall into one of them, even though I know they are there.
The prime causes for this accident are regulatory and would so far appear unaddressed. I therefore have some questions for the Egyptian Aviation Authority:
- Why was a Captain with such little experience of heavy jets permitted to command one?
- Why was a crew with such little heavy jet experience permitted to operate together?
- Why are you crews permitted to operate such long hours legally?
- Why is it left to Aviation Authorities of other countries to check the airworthiness of Egyptian registered aircraft?
The cause of the accident is clear and 95% definitive:
1. One section of Leading Edge Slats failed to retract after take-off, leading to some handling difficulties, however those difficulties are within the capabilities of a below-average pilot.
2. This handling problem is superimposed a background of:
- an inadequately experienced flight crew,
- crew fatigue,
- the lack of visual horizon on the night,
- both pilots becoming preoccupied with attempting to engage the autopilot.......whilst the aircraft takes a random path through the sky.
Someone one said, If you lay enough traps in my path then I am certain to fall into one of them, even though I know they are there.
The prime causes for this accident are regulatory and would so far appear unaddressed. I therefore have some questions for the Egyptian Aviation Authority:
- Why was a Captain with such little experience of heavy jets permitted to command one?
- Why was a crew with such little heavy jet experience permitted to operate together?
- Why are you crews permitted to operate such long hours legally?
- Why is it left to Aviation Authorities of other countries to check the airworthiness of Egyptian registered aircraft?
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The Egyptian authorities who cleared the Flash air captain of all possible fault in handling the aircraft are exactly the same as those that fought the NTSB tooth and nail over the responsibility of Gamil el Batouty, relief FO on Egyptair 990, for putting his 767 into the Atlantic in October 1999, despite overwhelming evidence to the contrary, and no evidence of an elevator failure, which was the Egyptian view. Apart from absolving all of responsibility, there is another common feature here.
Both Batouty and the Flash Air captain were honoured and revered members of the Egyptian Air Force, whose former chief is the recently re-elected president of the republic. The main Egyptian CAA investigators are also ex-air force. Anybody who found fault with either man would, inevitably, in an undemocratic country where patronage rules all, be thought guilty of bringing the nation into disrepute.
Patronage, jobs for the boys and cover-ups are inimical to air safety.
Both Batouty and the Flash Air captain were honoured and revered members of the Egyptian Air Force, whose former chief is the recently re-elected president of the republic. The main Egyptian CAA investigators are also ex-air force. Anybody who found fault with either man would, inevitably, in an undemocratic country where patronage rules all, be thought guilty of bringing the nation into disrepute.
Patronage, jobs for the boys and cover-ups are inimical to air safety.
ACCIDENT'S INVESTIGATION
Frangible
I understand that aviation safety should (?) be over national culuture and professional pride. However in some areas of the world face - saving exercises are of vital importants.
I would not discount the case where the official accident report states that it was an act of god that led to the crash, while at the same time internal action is being taken to prevent such an accident happens again.
My only concern is the quality and efficiency of the action taken.
Regards
Rwy in Sight
I understand that aviation safety should (?) be over national culuture and professional pride. However in some areas of the world face - saving exercises are of vital importants.
I would not discount the case where the official accident report states that it was an act of god that led to the crash, while at the same time internal action is being taken to prevent such an accident happens again.
My only concern is the quality and efficiency of the action taken.
Regards
Rwy in Sight
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There are 135 French families who have lost loved ones and are seeking some sort of closure to this episode. It seems at every turn the Egyptians are putting more time between the accident and their publishing of some sort of report in the hope that passions and expectations will fade.
It is probable that the report will make reference to the slat asymetry and say that the Captain made valiant attempts to save the aircraft against all odds but failed.
We know however that this condition is abnormal but quite controllable given a competant, alert (awake) crew.
Loss of face has no place in aviation safety.
It is probable that the report will make reference to the slat asymetry and say that the Captain made valiant attempts to save the aircraft against all odds but failed.
We know however that this condition is abnormal but quite controllable given a competant, alert (awake) crew.
Loss of face has no place in aviation safety.
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Originally Posted by Rwy in Sight
Frangible
I understand that aviation safety should (?) be over national culuture and professional pride. However in some areas of the world face - saving exercises are of vital importants.
I understand that aviation safety should (?) be over national culuture and professional pride. However in some areas of the world face - saving exercises are of vital importants.
Last edited by punkalouver; 10th Mar 2006 at 02:34.
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The SilkAir MI 185 and Egyptair 990 crashes were both deliberate acts. The Flash Air one was caused by gross incompetence. The reports of all three disasters will probably (upon release of the latest one) reflect "the saving of face" at all costs.
Such reports have NO place in the promotion of safety.
Such reports have NO place in the promotion of safety.