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MK Airlines B747 crash at Halifax

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MK Airlines B747 crash at Halifax

Old 2nd Jul 2006, 16:24
  #641 (permalink)  
 
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Rockhound,
Leave some of that crow for me will you.
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Old 2nd Jul 2006, 19:11
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Still only just over half way through the report. I think I get the implications as I "skipped" to the findings.

As usual, it seems to be a "chain of errors" (and I'm currently feasting on a bit of crow pie after my hasty comment earlier about the airline, although IMHO they received, and deserved, some of the blame)

My gut reaction is sadness and helplessness that these guys were lost when, had the locator antennas been on higher frangible masts, instead of a very solid earth and concrete berm, they would probably have "got away with it" and lived to fly another day (and "lesons learned"). Sad enough that 7 crew perished - had it been a passenger flight, the deaths would have been in the hundreds. For a few bob, the airport could have made things much more survivable for take-off problems or landing over-runs
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Old 3rd Jul 2006, 04:52
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Originally Posted by ExSimGuy
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My gut reaction is sadness and helplessness that these guys were lost when, had the locator antennas been on higher frangible masts, instead of a very solid earth and concrete berm, they would probably have "got away with it" and lived to fly another day (and "lesons learned"). Sad enough that 7 crew perished - had it been a passenger flight, the deaths would have been in the hundreds. For a few bob, the airport could have made things much more survivable for take-off problems or landing over-runs
Can't agree more, "if only".
Similar to the SQ crash in TPE - if only there had been a physical barrier to prevent the 747 from lining up on the closed runway
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Old 3rd Jul 2006, 09:16
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Just my opinion but looks like MK's PR is gently trying to distribute the blame; a spokesman, following the release of the report, described the conclusions about crew error as "speculation" (because of the lack of any CVR data) - and made a big effort to point out that someone was daft enough to put a soddin great berm in the way, and if it hadn't been there then the 747 might have got away with it.


"The lack of any data from the cockpit voice recorder meant the investigation would always contain a significant element of conjecture to ascertain precisely what went wrong. So sadly we can never be absolutely certain about the exact cause of a tragic accident in which we lost seven fine airmen, colleagues and great friends.

"In the absence of conclusive findings we conducted a comprehensive, proactive review of our operation to ensure that we meet the highest safety standards." - MK Airlines
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Old 3rd Jul 2006, 13:50
  #645 (permalink)  
 
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Very very sad and like almost all such major disasters a combination of things that have ben building up ... sometimes over years just waiting to come together all at once. And how tragic that a couple of seconds early crew reaction or a lower berm would have made such a difference.
I spent late Friday night reading the report with a deepening sense of forboding as I went through it.
One question comes to my inexperienced mind and I ask this as a simple Cherokee driver who has no experience of heavy metal.
Whatever the computed take off figure given, does not something in the experienced 747 pilots mind say that if a lightly loaded 747 rotated at 130 knots then that cannot be the same figure for a heavily loaded one ? What we all call a gross error check but one the brain carries our automatically.
Wouldn't the incorrect bug speeds and low EPR number have stuck out like a sore thumb?
Or are we simply being told that this was the insidious efect that fatigue had - a lack of "alertness".
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Old 3rd Jul 2006, 14:58
  #646 (permalink)  
 
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Quite frankly Dave, fatigue is often used as a convenient excuse for crews that fail to apply common sense, and actually watch what the hell they are doing.
I have seen the young inexpereinced as well as older guys fail to notice what the numbers are for various weights, and apply what you have called a gross error check.
This is especially apparent with FMS/FMC equipped aircraft...crew members look at the numbers, and accept them at face value, even though they couldn't possibly be right....forgeting the garbage in/garbage out principle.

Does fatigue play a factor?
Yes, sometimes...but I believe more often it is simply carelessness.

Example.

A well rested crew, beginning a long range flight, planned at max weight.
The Flight Engineer hands up the takeoff data card, which shows the correct loadsheet weight alright, but the V speeds selected are woefully short of whats required, and likewise with the thrust selected.
I handed the card back to the Flight Engineer and mentioned...you don't really believe this, do you?
He looks at it for about three seconds and says...'ah, well....No, opps, sorry Captain, wrong page.'
Precisely why the data should be closly checked by at least two folks.

FD crew should always be prepared to ask...does this look REASONABLE, and if not, do something about it, pronto.
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Old 3rd Jul 2006, 15:29
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Re KCl's post: Well, MK Airlines would say that, wouldn't they? It's no less reprehensible of them, however, to do so.
Re ExSimGuy and Makintw's posts: One should not lose sight of the fact that the berm did not cause the accident. Of course, it's a given that the area of a runway should be as free of obstructions as possible. The runway closure at TPE at the time of SQ006 was recent and temporary but, at the end of the day, even that cannot be used as an excuse for the actions of the SQ crew. The berm at YHZ was legal and a permanent fixture. In the event, say, of a catastrophic engine failure on takeoff, perhaps the presence of the berm would prevent a successful climb-out. In the case of the MKA accident, a fully airworthy aircraft was being operated in an unsafe manner. The reason for that is the crux of this tragedy.
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Old 3rd Jul 2006, 17:47
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MK Airlines: Halifax

I am disappointed that two-years later . . . the berms still exist at either end of this CAT-II runway. The ANS-provider has in fact installed similar berms at other airports in the country (identified in the TSB report). Apparently, the service provider continues to be unable to reconcile the cost of frangible structures and bases, versus the cheaper immovable objects. While it is only remotely possible that these structures could ever be the root-cause of an accident . . . guaranteed, they will be a topic for debate in future incidents.
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Old 3rd Jul 2006, 18:38
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does this look REASONABLE
some 30 years later, I can still remember (roughly) what EPR corresponded with heavy&short or light&long. Mostly did it by experience (of course, an error and an over-run did not kill me at Cranebank "Airport"!)
One should not lose sight of the fact that the berm did not cause the accident.
of course not, but if it hadn't been there (cost factor - "the cost of safety is only high until you see the cost of the lack of it"), the accident could maybe not have had the disastrous consequences that it did (and future accidents could be far more survivable!!)
a couple of seconds early crew reaction or a lower berm would have made such a difference
"Fortunately" that is usually the case - one malfunction (mechanical, crew, support, company) doesn't often cause and accident - if it did I wouldn't get on an aircraft! Sadly, sometimes all these things get together to bite you. All the industry can do is to try to eliminate as many as possible of the factors so that the "chain" does not get built up.

To that unlucky crew - "God be with you - rest in peace, hopefully your lives wil have been lost to save others - if we learn"
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Old 4th Jul 2006, 15:19
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ExSimGuy,
With respect, I beg to differ. The berm is a total red herring wrt this accident, except in that it helped to explain how the aircraft broke up.
If one follows your line of reasoning to its logical conclusion, one would have to conclude that, for example:
a. TPE, at the time of SQ006, when it was dark and the weather was bad, should have been closed to all traffic, because someone might have used the closed runway for takeoff or landing.
b. Tenerife airport, at the time of the KLM-Pan Am collision in 1977 when it was fogged in, should have been closed and no ground movements permitted, to prevent a collision.
c. No takeoffs or landings at any time, on any runway should have been allowed at YHZ while the berm was in place, as the possibility existed of an aircraft colliding with the berm. (If then you say the berm should never have been built in the first place, I couldn't argue with that. But how far do you take this no-obstacle-at-any-cost policy?).
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Old 4th Jul 2006, 23:20
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Right on Rockhound...

I've lucky more times than I can count in my measly 54 hours shy of 10,000...

A perfect example would be the time when I as an "experienced" Captain (over 4,000 hrs command on type at the time) departed a Southern US airport in a max gross 727 on a hot day...all three engines over-temped on take-off, but not until after V1/Vr...

What goes through the mind then? Fuel leak and fire on all 3?...bleed leaks on all three?...or something else?...You have just seconds to decide....try to stop and run off the end, or go up and lose everything?...

I decided in those few seconds that it was an "indication error" and continued, because I didn't want to believe it...(and we were past V1)

As it turned out I fried those JT-8D's because all [B]THREE[B]of us upfront didn't notice we commenced takeoff with the engine heat on on a 95 degree day...

If it doesn't look right, it probally isn't right...I should have aborted (even after V1) but on this occasion I got lucky....

However, not wanting to misplace the responsibility here, the slimy F/O immediately went to the CP to report the incident when we got back to domicile, not knowing I had all ready done so 2 days earlier...

Lessons learned...all the way around...
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Old 14th Jul 2006, 06:53
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With all due respest...

Rockhound..."The berm is a total red herring wrt this accident"

411A..."fatigue is often used as a convenient excuse for crews that fail to apply common sense, and actually watch what the hell they are doing"

And to all the other statements along these lines....

Fatigue was definitely a factor in this accident (imho). Anyone who disagrees should do the proverbial "sit in a dark closet with the vacuum-cleaner on" test for 19 hours and see how they fair with an average SAT test (or something similiar!)

Inadequate training on the performance computer definitely played a large part in this accident.

The berm definitely had something to do with the terrible demise of the crew and the aircraft.

How many other airfields are there in the world which have a large solid berm at the beginning/end of the runway? Not having been to too many myself, but I would hazard a guess that most pilots in the world would like to know this little pertinent piece of information (on the Jepp plate for instance) should there be one at the airfield at which they are operating into/ out of?

I'm not trying to suggest that the other factors should be ignored, but considering a quote from one of the links posted previously...

http://www.emediawire.com/releases/2005/4/emw233476.htm

"...On Wednesday 12 March 2003, at 1547, flight SQ286, a Boeing 747-412 registered 9V-SMT, started its take off at Auckland International Airport for a direct 9 hour flight to Singapore. On board were 369 passengers, 17 cabin crew and 3 pilots.

When the captain rotated the aeroplane for lift off the tail struck the runway and scraped for some 490 metres until the aeroplane became airborne. The tail strike occurred because the rotation speed was 33 knots less than the 163 knots required for the aeroplane weight.

The rotation speed had been mistakenly calculated for an aeroplane weighing 100 tonnes less than the actual weight of 9V SMT. The 389 persons on board had a very lucky escape. This aircraft did not crash mainly because there was no berm at the end of the runway..."

Unless I'm mistaken, there have been numerous similiar incidents at other airfields scattered around the globe, including two at Jnb? (An SAA 747-400 and an Emirates Airbus??? Please correct me if I'm wrong).(I do realise that incorrect (lower) thrust equates to incorrect (higher) weight... in these circumstances).

I just hope that we can all learn from what happened to those poor 7 souls in Halifax, and maybe be less critical and more constructive towards creating a safer environment for us all to work and play in.

With respect, in their memory....

"Captain Mike Thornycroft

Captain David Lamb

First Officer Gary Keogh

Flight Engineer Pete Launder

Flight Engineer Steve Hooper

Loadmaster Chris Strydom

Ground Engineer Mario Zahn

R.I.P."

css
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The Grass Isn't Always Greener Over There...
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Old 14th Jul 2006, 07:42
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What is Experience For ... If not ???

I would not doubt that fatigue plays some part - but I ask the same question again (I strongly make the point of being a lowly Cherokee driver who rotates about 65 knots whatever) that surely as a highly experienced heavy metal driver something in the brain screams "that cannot be right" if you have a computed take off speed of 130 knots for a heavily loaded machine whose take off speed needs to be 165 knots.
At what point does fatigue overcome aviators instinct and a captains thousands of hours of experience ???
Surely if somebody had been alert enough to recognise the incorrect speeds, the berm would never have come into it.
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Old 14th Jul 2006, 09:00
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Have you tried the hoover test yet? It varies with the individual, but tiredness is silent and deadly... ask anyone who's seen the black dog.....

Please keep this one thought in mind....

There are 4 probable times when you are most likley to kill yourself in aviation..

When you are released into the training area alone after your first 5 hrs solo..

When you get your first 100 hrs..

When you get your first 1000 hrs..

When ever you've done something a thousand times before, and you are tired...(and this applies to all aspects of life... tiredness kills.... and big dirt hills in your path certainly don't help!!!!)

You should only grade yourself on your worst performance in an aircraft... this is what people will remember. (a greaser is easily forgotten... a thumper (for whatever reason) will be immortal)

Just learn to read through the proverbial which you find in these threads, and hear in your flying club, and hang on to the important stuff which will save you one day and bin the rest... don't over-analyse everything you read/hear... big heavy-metal drivers are not infallible... experience certainly helps most of the time... but in this case all the holes in the cheeses lined up at the wrong time.

Keep the blue side up Dave......it is possible to survive a blind date with destiny!

Last edited by Bartholomew; 15th Jul 2006 at 10:20.
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Old 14th Jul 2006, 09:43
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Bartholemew is correct regarding fatigue. It is insideous and quite surprising what your mind will allow when heavily fatigued. That the crew did not recognise their error until too late is sad and maybe surprising to some however I have made some mistakes suffering under the effects of fatigue that I could not believe at the time. In one instance I put fuel in a tank that was snagged for a leak and MELed to home base. This was not picked up by anyone else on the crew and I first realised it at top of climb.

Dave Gittins

With the wide weight range that is possible with large transport aircraft V speeds can vary by 30 knots. If the Vr speed was within the range that could be experienced in a light weight B747 it is possible, given the fatigue, that no alarm bells rang in the minds of the crew.
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Old 14th Jul 2006, 10:31
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Hello,

Just a "anecdote" to proof..the fatigue is a factor of senseless errors.
One day (quiet sea ..full visibility) a supply ship stuck at good speed in a pontoon of our drilling rig....
No human casualties..thank's god.
In the examination who follow....the supply ship captain testimony he was sure (in his head) he was manoeuvring the engines control lever as he approach the rig...but in fact..due to his enormous fatigue (no sleep from 28 hours due to the fear of the first deck officer incompetency)..his body no react at his brain orders...
So...I believe the fatigue factor is one of importance.

Regards.
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Old 14th Jul 2006, 15:12
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Bartholomew,
We all know the berm had something to do with the accident but it had nothing to do with the [I]cause[I] of the accident. The berm was legal under regulations as they presently stand at YHZ. You appear to consider it an unacceptable hazard and if so it seems to me that logic would require that, were you in charge at YHZ, you would have kept the airport closed to all traffic until the berm was removed. My question was, would this restriction be reasonable? The question is certainly open to debate.
It appears that the accident was caused by straight pilot error. IMHO the focus should be on why the pilot error was committed and the appropriate lessons learnt.
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Old 18th Jul 2006, 00:43
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"[I]We all know the berm had something to do with the accident but it had nothing to do with the [i]cause of the accident."

Interesting..

(Here I go opening myself up to all sorts of abuse...)

If the berm wasn't there, would they have impacted Mother Earth?

With SQ286..." This aircraft did not crash mainly because there was no berm at the end of the runway..."

Considering the other 2 incidents in Jnb which I've previously mentioned, would they have had the same result if they had had to climb over a big earthen berm?

I am not trying to come to a conclusion as to the fault cause of the crash (the holes in the cheese did that already).... but consider if, in this case, the big earthen berm hadn't been there?


"RA indicated 36' prior to impact"

How many other incidents around the world haven't been recorded because there wasn't a big fat lump of dirt sitting at the end of the runway?

I might be wrong, but even after everything else that had gone wrong, these guys did their absolute best to get their beast into the air... and they would have succeeded..... but for the berm. Read through the other reports of the incidents I've mentioned, I don't think they would've got away with it in the same scenario?(should the berm have been there instead?)

Besides all else... these poor guys DID get their plane airborne... and SHOULD have climbed away... shaken and stirred, and probably would've dumped and returned to an investigation and a ****ting on, but would still be around to share a Scotch and a very illuminating story... BUT FOR THE BERM!

YES YES YES... I would close YHZ and every single other airport in the world who deem it necessary to place a BIG UGLY UNNECESSARY MOUND OF DIRT in the way of my aircraft which one day I might be trying to get itself into the air!!!

I don't think I'm alone in my thinking.....

If I am, then every other airport in the world should feel safe in putting a 50' block of flats at the end of every other runway which exists in the world? ,(Heathrow, Gatwick, JFK etc) If I am wrong, then please correct me?

If, like me, you feel that airports should be left obstruction free (within reason) please write in to this thread and help me out.

Rockhound... I'm not trying to pick a fight, all I'm asking is that you see reason in my explanation...they wouldn't have been there if they were doing things another way, or had more thrust or.... but.... at the end of it all... these poor guys saw the end of the runway coming, jammed up to radar thrust, dragged the poor girl off the floor on her arse, got her into the air.... and ran into a big lump of Canadian earth.

Fair?

I don't think so.
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Old 18th Jul 2006, 01:34
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MK Airlines:Halifax

I think my previous statement is correct; “While it is only remotely possible that these structures could ever be the root-cause of an accident . . . guaranteed, they will be a topic for debate in future incidents”

I do however wonder what goes through the mind of a pilot in charge, who has seen (in day-light) what is waiting off the end of the runway . . . hit the binders . . . or give-her-**** !?!

I hope I will never find myself present in this scenario . . .

Optimistically, we can all do what we can to eliminate these “No-Win” decisions ??????
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Old 18th Jul 2006, 17:49
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Bartholomew,
I quite understand what you're saying. Of course it was an unspeakable tragedy that the MK crew had to pay for their mistake with their lives. You readily confirm that, were you in charge, you would keep YHZ closed until the berm was removed. You have the courage of your convictions and I salute you for that. Personally, I think you're overreacting but that's just my opinion and I'm no expert, just an interested observer. If your policy were to hold sway, I'll bet a whole string of fields would have to be shut down and operations curtailed at many more.
You make a plea for airports to be obstruction-free but add a qualifier: "within reason". Ah, that's the rub. What exactly constitutes a reasonable obstruction? I guess on the matter of the YHZ berm, the top of which was at the same elevation as the end of the runway (because of the sloping terrain), we disagree.
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