MK Airlines B747 crash at Halifax
747Focal,
Unless I am missing something[list=1][*]No fire was present in this accident whist the aircraft was on the runway[*]Your zero g zero airspeed hindsight analysis of saying "max reverse thrust at the point this flight went to 1.6 EPR, they would have ended up with the airplane hitting the bearm at around 60 knots". It was dark, you have no or little depth and speed perception, and cannot see obstacles.[*] As already pointed out, 747 classics dont have an easy way to determine speed trends. [/list=1]
As for being on fire and coming back, yes get airborne, sort it out and land, thats exactly what a Cathay 744 did at LAX earlier this month.
There has been 7 incidents involving 747's in the past 2 months. 38 747 hull loss to date, which are increasing in frequency.
If you have any constructive facts to add that will shed light as to why this aircraft crashed please let us know, all I am seeing is speculation from the soap box.
Unless I am missing something[list=1][*]No fire was present in this accident whist the aircraft was on the runway[*]Your zero g zero airspeed hindsight analysis of saying "max reverse thrust at the point this flight went to 1.6 EPR, they would have ended up with the airplane hitting the bearm at around 60 knots". It was dark, you have no or little depth and speed perception, and cannot see obstacles.[*] As already pointed out, 747 classics dont have an easy way to determine speed trends. [/list=1]
As for being on fire and coming back, yes get airborne, sort it out and land, thats exactly what a Cathay 744 did at LAX earlier this month.
There has been 7 incidents involving 747's in the past 2 months. 38 747 hull loss to date, which are increasing in frequency.
If you have any constructive facts to add that will shed light as to why this aircraft crashed please let us know, all I am seeing is speculation from the soap box.
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Hmmm, I wonder if.....?
In one particular airline where I worked (and many, if not most of the Flight Engineers came from a large UK airline), the 'standard' procedure was for the handling pilot to stand the throttles up (to about 1.3 EPR) and ask the F/E to 'set takeoff thrust'...which he would normally promptly accomplish. MK's procedures perhaps?
Being of a slightly different mind (and briefed accordingly) I would set takeoff thrust approximately, and ask the F/E to 'set takeoff thrust'...which he would promptly do.
Now, if the F/E was a bit pooped, along with the rest of the crew, I can well imagine that the throttles were advanced to 1.3 EPR by the handling pilot, but it was never noticed (until a rather long time had passed), that the correct EPR was not set.
If this was the case, as I outlined....it sure was very unfortunate.
I wonder if we will ever know?
Being of a slightly different mind (and briefed accordingly) I would set takeoff thrust approximately, and ask the F/E to 'set takeoff thrust'...which he would promptly do.
Now, if the F/E was a bit pooped, along with the rest of the crew, I can well imagine that the throttles were advanced to 1.3 EPR by the handling pilot, but it was never noticed (until a rather long time had passed), that the correct EPR was not set.
If this was the case, as I outlined....it sure was very unfortunate.
I wonder if we will ever know?
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It's obvious pilots like discussing EPR's and v speeds but there has been little on the airline here. Is the fact that MK have lost four aircraft over the last 12 years significant? How many a/c do they operate? I'm pretty sure that if any passenger airline lost the same proportion of its fleet it would be headline news.
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B747'
I am afraid that your 15% "slop" is very hypothetical.
Initial performance is carried out by the manufacturer in order to compile the AFM which everyone then uses for ever
The question about FAA v UK CAA was because if you take an FAA AFM for a given aircraft ( by serial number) and then take a UK CAA AFM ( if issued) for the same aircraft you will come out with different limitation figures.
These initial figures are compiled with a new aircraft ( no dents or dings and full fit and fair) with new engines ( adjusted, per the manual for that specific flight test) with all new components including brakes and using test flight instrumentation and accurately measured distances.
The 15% "slop" is there to take care of deterioration in service which most certainly happens.
Therefore the "slop" theory is true on a new aircraft but most cerainly is not there on a 20 year old machine.
A good example of this is MGWRTO.
We used manuals for many years that said if you perfom like this and abort at this speed you will stop before the end of the runway.
It took the DC10 RTO in New York that went off the end to show that this is not true if you have worn ( but perfectly legal) brakes.
The result was an AD that reduced brake wear allowance.
This was a shortcoming that was eventaully highlighted bercause of positive in service proof.
This is not the case for take off performance where if the take off is made sucessfully no one ever queries if the obstale was cleared by 35 or 55 feet.
I have been involved ( after the event !) on several RTO's including a manufacturers test program. On the test program the wheel fuse plugs did not let go until right at the end of the landing run.
On the ones I have seen in service the fuse plugs blew very early on in the abort, ( a worn brake cannot absorb the heat as efficiently as a new one) which resulted in loss of braking in service that did not occur on test.
In the UK the CAA require we do test flights on in service aircraft to try to determine any perfomance degradation. (Not an FAA requirement). We obviously cannot do any definitive take off performance but we do do MTOW engine out climbs.
While we have no set limits we just compare with the book and believe me not many 20 years old aircraft exceed the book figures.
I am afraid that your 15% "slop" is very hypothetical.
Initial performance is carried out by the manufacturer in order to compile the AFM which everyone then uses for ever
The question about FAA v UK CAA was because if you take an FAA AFM for a given aircraft ( by serial number) and then take a UK CAA AFM ( if issued) for the same aircraft you will come out with different limitation figures.
These initial figures are compiled with a new aircraft ( no dents or dings and full fit and fair) with new engines ( adjusted, per the manual for that specific flight test) with all new components including brakes and using test flight instrumentation and accurately measured distances.
The 15% "slop" is there to take care of deterioration in service which most certainly happens.
Therefore the "slop" theory is true on a new aircraft but most cerainly is not there on a 20 year old machine.
A good example of this is MGWRTO.
We used manuals for many years that said if you perfom like this and abort at this speed you will stop before the end of the runway.
It took the DC10 RTO in New York that went off the end to show that this is not true if you have worn ( but perfectly legal) brakes.
The result was an AD that reduced brake wear allowance.
This was a shortcoming that was eventaully highlighted bercause of positive in service proof.
This is not the case for take off performance where if the take off is made sucessfully no one ever queries if the obstale was cleared by 35 or 55 feet.
I have been involved ( after the event !) on several RTO's including a manufacturers test program. On the test program the wheel fuse plugs did not let go until right at the end of the landing run.
On the ones I have seen in service the fuse plugs blew very early on in the abort, ( a worn brake cannot absorb the heat as efficiently as a new one) which resulted in loss of braking in service that did not occur on test.
In the UK the CAA require we do test flights on in service aircraft to try to determine any perfomance degradation. (Not an FAA requirement). We obviously cannot do any definitive take off performance but we do do MTOW engine out climbs.
While we have no set limits we just compare with the book and believe me not many 20 years old aircraft exceed the book figures.
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Safety Guy
My companys SOP requires a briefing and the normal call of at or above V1 I will continue the T/O etc. On every T/O I practice all the what ifs because the biggest factor is the element of surprise followed by the identification of the problem, things that should, but cant all be taught in the simulator.
You would be surprised at how fast the auto braking system can stop a 767 on a cold winter morning and yes you do coast past V! due to the reaction time.
In this business many life and death decisions are unfortunately made in the grey area and that is why situational awareness is so important. On occasion you have to step outside the box to save the day.
Mutt
No one was suggesting doing a RTO once in the air. The SOPs are designed to cater to the lowest common denominator and do not take into account situational awareness. However it is rare that everything abnormal happens according to the book, wish they did but thats not reality. If you really want to teach your troops a valuable lesson demonstrate to them the element of surprise...
When youre in the simulator your candidates are expecting failures, in line operations therere not. Big difference
My companys SOP requires a briefing and the normal call of at or above V1 I will continue the T/O etc. On every T/O I practice all the what ifs because the biggest factor is the element of surprise followed by the identification of the problem, things that should, but cant all be taught in the simulator.
You would be surprised at how fast the auto braking system can stop a 767 on a cold winter morning and yes you do coast past V! due to the reaction time.
In this business many life and death decisions are unfortunately made in the grey area and that is why situational awareness is so important. On occasion you have to step outside the box to save the day.
Mutt
No one was suggesting doing a RTO once in the air. The SOPs are designed to cater to the lowest common denominator and do not take into account situational awareness. However it is rare that everything abnormal happens according to the book, wish they did but thats not reality. If you really want to teach your troops a valuable lesson demonstrate to them the element of surprise...
When youre in the simulator your candidates are expecting failures, in line operations therere not. Big difference
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and i still would like to learn why the CVR was damaged:
TSO Date Impact requirements Fire test requirements
C51 Aug. 1958 100G for 11ms The recording medium shall remain intact so that intelligence can be analyzed after the recorder has been exposed to flames of 1100 C, enveloping at least 50% of the outsuide area of the case for 30 minutes.
C84 Nov. 1963 100G for 11ms [same as TSO C51]
PLUS: Any cracks or holes resulting from the impact shock test be included in the 50% flame envelopment, and that the recorder be allowed to cool naturally.
C51a Jan. 1966 1000G for 5ms [same as TSO C51]
PLUS: Impact shear ~ 500lbs. from 10',1/4" pin adn Static crush ~5000lbs. 3 sides, 5min.
C123 May 1991 1700G for 6.5ms 1100 C, flame enveloping 100% of the outside area of the case for 30 minutes, 50000BTU/h thermal flux.
Note: does not require TSO C124 fire test protocol. (Ref. EUROCAE Doc ED-56)
C124 Feb. 1992 3400G for 6.5ms [same as TSO C123]
EXCEPT thermal flux must be measured by a water calorimeter of the size and shape of the recorder. (Ref. EUROCAE Doc. ED-55)
--------------------------------------------------------------------------------
References:
NTSB Safety Recommendations A-92-45 through -48 / National Transportation Safety Board (NTSB), May 28, 1992
--------------------------------------------------------------------------------
If i assume that the cvr was located in the back of the plane
which separated from the rest of the plane while still on the runway two questions come to mind:
1. How hard was the impact when the tail separated ?
I assume by far not as hard as coming down vertically from
some 1000 feet ....
2. Was the tail exposed to fire ?
or was the CVR simply not working ? i'm not sure whether
the CVR is an item in the MEL.
sorry if this was discussed anywhere in the 30+ pages before ...
TSO Date Impact requirements Fire test requirements
C51 Aug. 1958 100G for 11ms The recording medium shall remain intact so that intelligence can be analyzed after the recorder has been exposed to flames of 1100 C, enveloping at least 50% of the outsuide area of the case for 30 minutes.
C84 Nov. 1963 100G for 11ms [same as TSO C51]
PLUS: Any cracks or holes resulting from the impact shock test be included in the 50% flame envelopment, and that the recorder be allowed to cool naturally.
C51a Jan. 1966 1000G for 5ms [same as TSO C51]
PLUS: Impact shear ~ 500lbs. from 10',1/4" pin adn Static crush ~5000lbs. 3 sides, 5min.
C123 May 1991 1700G for 6.5ms 1100 C, flame enveloping 100% of the outside area of the case for 30 minutes, 50000BTU/h thermal flux.
Note: does not require TSO C124 fire test protocol. (Ref. EUROCAE Doc ED-56)
C124 Feb. 1992 3400G for 6.5ms [same as TSO C123]
EXCEPT thermal flux must be measured by a water calorimeter of the size and shape of the recorder. (Ref. EUROCAE Doc. ED-55)
--------------------------------------------------------------------------------
References:
NTSB Safety Recommendations A-92-45 through -48 / National Transportation Safety Board (NTSB), May 28, 1992
--------------------------------------------------------------------------------
If i assume that the cvr was located in the back of the plane
which separated from the rest of the plane while still on the runway two questions come to mind:
1. How hard was the impact when the tail separated ?
I assume by far not as hard as coming down vertically from
some 1000 feet ....
2. Was the tail exposed to fire ?
or was the CVR simply not working ? i'm not sure whether
the CVR is an item in the MEL.
sorry if this was discussed anywhere in the 30+ pages before ...
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GotTheTshirt,
I would agree that the "slop" is larger for new aircraft, but your going to have a hard time convincing me that commercial aircraft degrade performance by anywhere near 15% over their lifetime.
The manufacturers use about an 80% confidence margin. That means they use some percentage less than what was actually tested when they make guarantees.
Do you really think an operator would tolerate a 15% degredation in performance over time?
I would agree that the "slop" is larger for new aircraft, but your going to have a hard time convincing me that commercial aircraft degrade performance by anywhere near 15% over their lifetime.
The manufacturers use about an 80% confidence margin. That means they use some percentage less than what was actually tested when they make guarantees.
Do you really think an operator would tolerate a 15% degredation in performance over time?
There has been a large volume of doctrinal discussion about the decision to take at V1.
The unspoken premise in decision making at V1 is that the a/c has accelerated normally to V1 -- did not happen here.
This accident is closer to what the winch glider folks call a "slow launch".
In both cases, if you let it go too far, you run out of runway before you are ready to fly.
The unspoken premise in decision making at V1 is that the a/c has accelerated normally to V1 -- did not happen here.
This accident is closer to what the winch glider folks call a "slow launch".
In both cases, if you let it go too far, you run out of runway before you are ready to fly.
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411a, your theory about what might have happened in the cockpit could be verified with MK's SOPs. Anyway it sounds like a reasonable possibility.
The debate over V1 and when you might possibly consider violating it, shows the gray area that the events of this accident happened in. I agree with RatherBeFlying, as this was the equivalent of a glider winch "slow launch". Because V1 was reached late in the under powered takeoff roll, the V1 the pilots calcuated was NOT the V1 they actually arrived at.
At this point, the decision that has to be made, when you discover at V1 that you arrived at V1 under powered, gets very murky. What you should do at this point really depends on the runway and where you are on it. In a situation like this accident where it probably wasn't easy to quickly determine the remaining distance down the runway, the "go no-go" decision that has be made very quickly is going to be a guess at best.
I can't imagine without more situational awareness (electronic or othwerwise), that the murkiness of this type of decision will ever get any clearer.
There was a thread running for a time in the Tech forum that discussed the development of TOPMS (a Take Off Performance and Monitoring System). While ongoing efforts may eventually provide a system that will communicate to the pilots that the takeoff is "off the numbers" early in the takeoff run (so you can really do something about it), such a system will not be available on all airliners for some time.
Until this happens, it seems to me that the best "performance monitoring system" commonly available, that would help a pilot to avoid getting into this dangerous "gray area" of an "off the numbers" V1, is the good old stop clock. Used properly, the stop clock can let you know early enough to make a good decision. SOPs would be needed to avoid false RTOs, etc, since this doesn't appear to be a very common practice.
The best thing to do is to never get into the situation these pilots were in, in the first place. Once there, without good situational awareness to help with this critical decision making, you're in very deep weeds with no obvious way out.
The debate over V1 and when you might possibly consider violating it, shows the gray area that the events of this accident happened in. I agree with RatherBeFlying, as this was the equivalent of a glider winch "slow launch". Because V1 was reached late in the under powered takeoff roll, the V1 the pilots calcuated was NOT the V1 they actually arrived at.
At this point, the decision that has to be made, when you discover at V1 that you arrived at V1 under powered, gets very murky. What you should do at this point really depends on the runway and where you are on it. In a situation like this accident where it probably wasn't easy to quickly determine the remaining distance down the runway, the "go no-go" decision that has be made very quickly is going to be a guess at best.
I can't imagine without more situational awareness (electronic or othwerwise), that the murkiness of this type of decision will ever get any clearer.
There was a thread running for a time in the Tech forum that discussed the development of TOPMS (a Take Off Performance and Monitoring System). While ongoing efforts may eventually provide a system that will communicate to the pilots that the takeoff is "off the numbers" early in the takeoff run (so you can really do something about it), such a system will not be available on all airliners for some time.
Until this happens, it seems to me that the best "performance monitoring system" commonly available, that would help a pilot to avoid getting into this dangerous "gray area" of an "off the numbers" V1, is the good old stop clock. Used properly, the stop clock can let you know early enough to make a good decision. SOPs would be needed to avoid false RTOs, etc, since this doesn't appear to be a very common practice.
The best thing to do is to never get into the situation these pilots were in, in the first place. Once there, without good situational awareness to help with this critical decision making, you're in very deep weeds with no obvious way out.
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747FOCAL,
We are still not on the same wavelength. You say:
I don't know why the crew only moved the thrust levers to 1.6 when they realized something was wrong. All I have is the data. Death has coverd his tracks on this one.
Yet in an earlier post you said:
At no time was the throttle firewalled. Somebody on the flight deck knew the proper throttle setting. It was set incorrectly. To move the throttle levers deliberately from 1.3 to the EXACT EPR it should have been leads me to believe it was just a simple mistake. If they had firewalled the throttles, that would have meant they realized they weren't using enough thrust but not know what it really should be.
(By EXACT EPR I presume you mean 1.6). You now seem to believe that Crewmember X advanced the throttles to 1.6 because he realized something was amiss, rather than to simply correct a mistake (throttles set too low) that he happened to notice at around V1.
It still seems to me that the crew massively underestimated their weight and were confident that a setting of 1.6 EPR was more than enough to get them airborne, i.e. there was no sense of panic at V1.
Do you now think one or more of the crew sensed something was amiss at V1?
BTW has someone calculated what the correct thrust setting was for the conditions? Surely it was higher than 1.6?
As regards my question about throttle adjustments during TO, Mutt has provided an indirect answer. As I understand it, adjustments other than fine-tuning (trimming) the setting so that all engines are developing PWR equally should not be undertaken. Correct?
Rockhound
We are still not on the same wavelength. You say:
I don't know why the crew only moved the thrust levers to 1.6 when they realized something was wrong. All I have is the data. Death has coverd his tracks on this one.
Yet in an earlier post you said:
At no time was the throttle firewalled. Somebody on the flight deck knew the proper throttle setting. It was set incorrectly. To move the throttle levers deliberately from 1.3 to the EXACT EPR it should have been leads me to believe it was just a simple mistake. If they had firewalled the throttles, that would have meant they realized they weren't using enough thrust but not know what it really should be.
(By EXACT EPR I presume you mean 1.6). You now seem to believe that Crewmember X advanced the throttles to 1.6 because he realized something was amiss, rather than to simply correct a mistake (throttles set too low) that he happened to notice at around V1.
It still seems to me that the crew massively underestimated their weight and were confident that a setting of 1.6 EPR was more than enough to get them airborne, i.e. there was no sense of panic at V1.
Do you now think one or more of the crew sensed something was amiss at V1?
BTW has someone calculated what the correct thrust setting was for the conditions? Surely it was higher than 1.6?
As regards my question about throttle adjustments during TO, Mutt has provided an indirect answer. As I understand it, adjustments other than fine-tuning (trimming) the setting so that all engines are developing PWR equally should not be undertaken. Correct?
Rockhound
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Its clear that V1 is critical only if reached before a certain distance on the runway. We have had odometers in cars for a long time, why not a simple 'Distance measuring counter' hooked to the landing gear to measure the actual t/o run?
Last edited by Smurfjet; 19th Nov 2004 at 00:10.
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B747, Performance degradation.
Well the RTO certainly degraded by 15 % when the DC 10 AD came out.
I have had aircraft on UK test flights where we have re-rigged flight controls to improve performance.
This became apparent on a Cof A test flight but prior to the test flight the aircraft was flying in service.
How many times have you gone back on a test/handling/ ferry flight and have seen spoiler float or flap droop.
This inspection does not happen on revenue flights but as a pax I have seen these anomolies.
One other point is that , using derated power take offs does not guarantee that the engine will give max power when firewalled.
On maintenance checks we do check the engine slam acel times and on occasions have to ajdust them.
If we have to adjust this it indicates that the engine did not perform per the specs prior to the check!
All I am saying is that aircraft do degrade in service but hopefully stay within the "slop"
Well the RTO certainly degraded by 15 % when the DC 10 AD came out.
I have had aircraft on UK test flights where we have re-rigged flight controls to improve performance.
This became apparent on a Cof A test flight but prior to the test flight the aircraft was flying in service.
How many times have you gone back on a test/handling/ ferry flight and have seen spoiler float or flap droop.
This inspection does not happen on revenue flights but as a pax I have seen these anomolies.
One other point is that , using derated power take offs does not guarantee that the engine will give max power when firewalled.
On maintenance checks we do check the engine slam acel times and on occasions have to ajdust them.
If we have to adjust this it indicates that the engine did not perform per the specs prior to the check!
All I am saying is that aircraft do degrade in service but hopefully stay within the "slop"
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Smurfjet,
BA had these 'distance to go' indicators on their TriStars....and along with PVD, worked like a charm.
Sadly, when 'other' airlines got the aircraft, these were the first items to be deactivated.
BA had these 'distance to go' indicators on their TriStars....and along with PVD, worked like a charm.
Sadly, when 'other' airlines got the aircraft, these were the first items to be deactivated.
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Tan:
The mathematical result in my last posting was wrong because I turned the 4,000 ft you said you had left into 6,000. I made a mistake, okay?
I didn't mean to be a smart ass, honest.
As far as I know, there are very few people on this forum who've had your particular experience, i.e. a real engine failure at a critical point of the takeoff. I asked a question so that I (and others) could benefit from your experience. I don't fly the 767. The aircraft I fly operates at or near max TOW most of the time, and I know that it won't duplicate the performance you had that day. Your V1 that day is one I would only see with half a load on board. Believe me, I wish it would perform like the 767!
I agree that maintaining good situational awareness is important. You've stated that the reject was completed once V1 was reached. Thanks to a good result with no damage or injuries, you are able to justify your actions on that day. I would argue that continuing the takeoff would probably have brought a similar result. I hope neither of us ever has to find out.
The Captain has the ultimate authority in deciding how to proceed in an emergency, including use of deviations from the SOPs and training. When a deviation from standard practice leads to a positive result, everybody wins. When it doesn't, we also get to answer for it.
SG
The mathematical result in my last posting was wrong because I turned the 4,000 ft you said you had left into 6,000. I made a mistake, okay?
I didn't mean to be a smart ass, honest.As far as I know, there are very few people on this forum who've had your particular experience, i.e. a real engine failure at a critical point of the takeoff. I asked a question so that I (and others) could benefit from your experience. I don't fly the 767. The aircraft I fly operates at or near max TOW most of the time, and I know that it won't duplicate the performance you had that day. Your V1 that day is one I would only see with half a load on board. Believe me, I wish it would perform like the 767!
I agree that maintaining good situational awareness is important. You've stated that the reject was completed once V1 was reached. Thanks to a good result with no damage or injuries, you are able to justify your actions on that day. I would argue that continuing the takeoff would probably have brought a similar result. I hope neither of us ever has to find out.
The Captain has the ultimate authority in deciding how to proceed in an emergency, including use of deviations from the SOPs and training. When a deviation from standard practice leads to a positive result, everybody wins. When it doesn't, we also get to answer for it.
SG
Last edited by Safety Guy; 19th Nov 2004 at 02:17.
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Could a 747 driver tell us what reduced thrust takeoff numbers for the takeoff out of Hartford would have been?
I think you will find that they are similar to what was used in YHZ. The airspeed indicator bugs if not destroyed will show if the Hartford V-speeds were used. If the old takeoff data card was used accidentally instead of the newly calculated numbers this would explain a lot.
I think you will find that they are similar to what was used in YHZ. The airspeed indicator bugs if not destroyed will show if the Hartford V-speeds were used. If the old takeoff data card was used accidentally instead of the newly calculated numbers this would explain a lot.
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747FOCAL,
I presume your last post is a response to mine. This is the first I've heard that they pulled the nose up at V1. I was merely reproducing what you wrote earlier, i.e. at or around V1, a crewmember advanced the throttles from 1.3 to 1.6 EPR to correct a "simple mistake". This reported action does not sound panic-stricken to me.
Rockhound
I presume your last post is a response to mine. This is the first I've heard that they pulled the nose up at V1. I was merely reproducing what you wrote earlier, i.e. at or around V1, a crewmember advanced the throttles from 1.3 to 1.6 EPR to correct a "simple mistake". This reported action does not sound panic-stricken to me.
Rockhound
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Rockhound,
Even though it has already been discussed in this thread, the crew pulled the nose once and set it down, then pulled it again as they left the paved runway.
You can lie to yourself all you want, but at V1 at least one person on that flight deck knew they probably were not going to make it.
Even though it has already been discussed in this thread, the crew pulled the nose once and set it down, then pulled it again as they left the paved runway.
You can lie to yourself all you want, but at V1 at least one person on that flight deck knew they probably were not going to make it.