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AA 587 Final Report

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AA 587 Final Report

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Old 9th Dec 2004, 15:14
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After several years of posting and reading posts here at PPrune, I have an observation to make regarding accident discussions.

When contributing factors to an accident like this one, includes both a training problem (or a pilot performance problem), and a potential aircraft design problem, both factors are legitimate contributing causes. In this accident the NTSB found that both training AND an aircraft design anomaly contributed to this accident, and it's their job to determine if multiple contributing causes exist.

I've noticed over the years that a number of pilots posting here seem to lean toward the training human performance causes, while tending to lean away from a potential design issue. In some ways this is understandable, given that training is commonly used to overcome a potential design problem, and training is the ONLY thing a pilot can do to prevent the next accident, since making an aircraft's design better is completely outside the control of nearly every pilot.

Still, my observation is that the constant back and forth of arguing whether it's "training" or it's "design" is not very productive. Gentleman, learning from an accident is NOT whether the fault was training OR design, but rather that real understanding comes from knowing that BOTH were contributing causes to this accident, and BOTH topics are worthy of full and complete discussion. Each person may focus on one issue or the other, but one issue does NOT cancel out the other.

OK I'm done now, thanks for listening.
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Old 9th Dec 2004, 15:43
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Angel

DR DAVE

Would like to be your patient. Sounds reasonable.

FLIGHT SAFETY

"Findings:
14. Because of its high sensitivity (that is, light pedal forces and small pedal
displacements), the Airbus A300-600 rudder control system is susceptible to
potentially hazardous rudder pedal inputs at higher airspeeds."

As someone who logged quite an amount of hours on that AC I do not fully agree. But keeping the big picture in sight as you say its probably a contributing factor and therefore I will swallow it.
As there has been an amazing misunderstanding of rudder application and limits to that in our pilot community we all might
gain some profit from the NTSB report for a safer future operation.
Fully agree with your post. Therefore: Last post concerning AA 587.

Regards

Last edited by Captain104; 10th Dec 2004 at 09:49.
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Old 10th Dec 2004, 13:17
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Wino,

I certainly cannot agree with your reasoning.

Altho the A300-600 may indeed have a poorly or oddly designed rudder limiter from a pilots perspective, nevertheless if American Airlines had not institued their Anvanced Maneuvering Course, as it was at the time, and insisted that pilots use the rudder in an excessive manner during so called 'upsets', AA587 would undoubtedly not have crashed.

And, even if you further claim that the specific maneuvering course was not designed with the idea of using the rudder to an excessive degree, American is still guilty of not using due care in supervising and training properly the First Officer in question, who clearly on previously reported circumstances, was known to have used excessive rudder on previous flights, even in other aircraft.

So, American Airlines, even if they did not know of any deficiency with the A300-600 rudder limiter, nevertheless showed very poor thought process in designing and implementing the advanced maneuvering course in the first place, knowing full well that excessive rudder inputs are very bad news at higher speeds.

Oddly enough, American Airlines was the first US operator to have a problem with large rudder inputs (due to a hydraulic actuator problem), when an AA B707 experienced a rudder hardover in 1960, departing IDL (now JFK), and went straight into the drink in Flushing Bay, with all on board lost.
Altho this particular accident with the 707 was not the result of pilot induced inputs, it nevertheless aptly demonstrates just what can happen to an aircraft, when the rudder travels to the stops, pilot induced or otherwise, at inappropriate times.

A pig is a pig, no matter how much lipstick you put on it.

AA is guily as hell, and the NTSB report is right on target, in my opinion.
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Old 13th Dec 2004, 04:04
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Decided to un-block the old man for a change and read his posting....

Strangely enough, I partly agree with his statement about not re-checking Sten's understanding of rudder use, if that was what was at fault. But then, it's my observation from flying here in the US, both on exchange in the military and in the airlines, that a great deal of the training is just "filling boxes" and ticking squares to graduate a gradesheet at minimum cost. I have been horrified at some of the questions I have been asked by both students and instructors alike, and when probed deeper, the complete lack of in-depth understanding. Answers are vomited out parrot-fashion. The written exams are a good example. Students learn to pick the correct answer out of a collection without any understanding of the mechanisms at work; minimum cost, minimum delay....quickest route to that "dream job at our school affiliated commuter airline". Hmmmm.

Let's examine the rest of 411a's posting and daily AA rant....

"...aptly demonstrates what happens..." Absolute rubbish.
The 707 accident was ultimately a loss of control, but not caused by structural failure or crew action. It no more demonstrates it than any other flight control abnormality-caused accident. There was no blame placed on the 707 crew by the NTSB and for you to relate the two is pathetic. Don't confuse the "youngsters" out there that you love to haze on. Loss of control from full-deflection of the rudder is different from structural failure of the base of the fin from exceeding the design strength side-loads on the bracket.

"...the first US operator to have rudder problems....". More complete rubbish. I suspect the Wright Brothers were the first. Plenty of other transport aircraft prior to the 707 had insufficient rudder and/or other problems in directional stability or vertical stabilizer failure. Vmca was discovered prior to you, mate. In fact, the dutch roll phenomena affecting early 707's and KC-135's was well before the Flushing smash, leading to the fin extension and lower strakes on the Intercontinental.

I strongly suspect 411a's career looks like this:

Flew for PanAm
Got laid off by PanAm in the 80's after enduring years of their dinosaur-speed seniority system just as he was getting somewhere
Bitterly blames the "Big 3" for putting PanAm out
Goes searching round the world for a job (too old for starting over in the US)
Lands at SQ, great place to practice CRM
Ah, but home beckons....back to Az to try his hand
Still very bitter at the Big 3, and the CX blokes (from seeing their A-scales when he was at SQ)
If AA, UA, or DAL went under, he'd be very happy - revenge!

Oh, here's an interesting tit-bit:

PanAm's fatalities per million miles is higher than AA's, including an absolutely disgusting 9 fatal accidents (7 involving 707's) during the time you were probably there (1971-1982), killing well over a 1000 passengers. It's quite clear their management didn't learn anything from the "old hands" around at the time. Apparently lessons learnt were ignored at PanAm....

Some people never learn, blah, blah....

Last edited by RRAAMJET; 13th Dec 2004 at 04:40.
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Old 13th Dec 2004, 08:20
  #25 (permalink)  
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Hi PRAAM

All you said, even about 411a, sounds very reasonable

and after this one:
>>" Plenty of other transport aircraft prior to the 707 had insufficient rudder and/or other problems in directional stability or vertical stabilizer failure. Vmca was discovered prior to you, mate. In fact, the dutch roll phenomena affecting early 707's and KC-135's was well before the Flushing smash, leading to the fin extension and lower strakes on the Intercontinental. <<

did not we come full circle on this topic?

A300 HAD sufficient rudder...
 
Old 13th Dec 2004, 10:29
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Personally,the only bit about an Airbus I trust are the wings(built by the Brits).This rudder separated just above design load limits.Well,thats fine.Keeps Airbus out of court but its not exactly a great testimony to Airbus.Boeings have been pulling g's well in excess of design limits for years.They're built stronger.MD's too.And Lockheed strongest of all.Wino's arguments are more persuasive than others.The only comeback seems to be "Airbus build weak rudders.Know that and act accordingly and you'll be fine"
However,having said that,I have huge respect for the NTSB and if they found something amiss at AA,then I'd back them.Perhaps this unfortunate crew had been given the wrong training.But then as Wino points out, AA flies an awful lot of flights so why didnt this show up on other fleets?
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Old 13th Dec 2004, 10:58
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Rananim,

It was the vertical stabiliser that separated, and according to the conclusions of the NTSB report, at loads that were:

"about twice the certified limit design envelope and were more than the certified ultimate load design envelope"

GB.
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Old 13th Dec 2004, 11:27
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Rananim I think the DHL pilots who guided an A300 back to SDA having been hit by a surface-to-air missile might disagree with you there......seems to me Airbus put their aircraft together very well indeed!
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Old 13th Dec 2004, 15:36
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It would appear that good 'ole RRAAMJET has been sniffing at the glue pot once again.
Soory old bean, but never worked at PanAmerican, only trained there, as did so many others...who wanted the best training there was.

Then again, quite unlike some at AA (past and present), I never crashed an airplane or injured a passenger...sadly, something AA has never been able to say.

Cali, Little Rock, Bradford, Denver...and these are just the more recent examples, never mind the JFK departing Airbus.
Poor technique, poor training, bent aeroplanes...the hallmark of American Airlines...and the record speaks for itself.
The NTSB is spot on with their report.
The AA first officer crashed the aeroplane, pure and simple.
Lawyers will have a field day, and the billable hours will be in the many thousands.
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Old 13th Dec 2004, 15:46
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Renanim, you said 'Boeings have been pulling g's well in excess of design limits for years.They're built stronger.'

That is presumably not the same Boeing company that had:
- a 747 disintegrate over the South China Sea for no discernable reason (and this is not the first 747 structural problem surely?)
- a 767 crash due to uncommanded, in-flight reverse thrust operation
- a series of 737 losses due to rudder reversal
- a 737 go 'cabriolet' near Hawaii, with the loss of a flight attendant
- a Boeing-repaired rear bulkhead fail on a 747, with the resultant loss of the aircraft

Presumably that was a different Boeing?

Not trying to devalue any of these tragic events, just to point out that Airbus is not the only imperfect manufacturer of aircraft.

Dr Dave
 
Old 13th Dec 2004, 18:03
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Talking

"...the best training there was..." ended up wrecking 9 jets in 10 years. Dream on....glad I'm not a pax behind you.

Far safer operations, and better training, existed apparently...

Some old duffers never learn, blah blah....
Apparently the lessons were not learnt blah blah....
How many Asian islands have a 707 imbedded in them from the 70's....

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Old 13th Dec 2004, 20:25
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On the other hand RRAAMJET, 'ole buddy, apparently the AA 707 crew I mentioned couldn't find the rudder power switch...just overhead the Captains position, something the original Boeing procedures stressed quite well.
Why am I not surprised.

ALL of the recent AA accidents/incidents have been directly related to improper crew actions. Yes, Cali, Little Rock, Bradford, Denver, not to mention AA587.

Look at other US trunk carriers, and not one of 'em have had this sad record.

Hardly surprising, with American Airlines arrogant attitude.
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Old 13th Dec 2004, 23:20
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Talking

So, in other words, a technical fault and not crew error, and totally unrelated to 587 and you're waffling. Who knows what the cockpit g-forces or otherwise were in that scenario in Flushing. Go ahead and condemn the crew as usual....

Certainly nothing like controlled flight into the top of Bali or any number of other "...best training available..." scenarios, eh? How's about missing the correct turn-off in Tenerife....

Some people never learn.....
Lessons weren't learnt.....

411a word association quiz:

"Glass" "Houses" "Stones"



Oh, and Bradford is in Yorkshire, and a very nice little airport, too, I might add, Bradley ( BDL) is an airport near Hartford, Conn....anybody with a modicum of professional aviation quality training would know that, but apparently that wasn't available in the "...best available...". Glad you're not a navigator, too.

Some people never learn, blah, blah....


Last edited by RRAAMJET; 13th Dec 2004 at 23:31.
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Old 14th Dec 2004, 00:08
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Indeed, RRAAMJET BDL it was, a perfectly serviceable aircraft flown into the trees.
Denver, just recently I might add...unstable approach found some of the frangible bits of the approach lights.
LittleRock, with a system chief pilot (no less) off the end, trying to land in a thunderstorm.
And, the worst of all, Cali, where a totally confused crew ran right smack into a hill, because they could't follow the most basic of instruments, the RMI, which should have been tuned to the proper LF beacon, but ignored by this crew, so pre-occupied they were with entering incorrect data into the FMC, and then finding themselves in deep doggie do-do, tried to climb away, with the spoilers still extended.

A sorry record, would't you agree?

But then again, an AA pilot would be inclined to dismiss all this as just bad luck, or perhaps faulty equipment.

Others, more objectively concerned with a definite pattern of deficient training, simply can't agree.

AA587 was no different. Nothing wrong with the aeroplane, yet the vertical fin departed, according to the NTSB, because the handling pilot overused the rudder...in the extreme.
If there was anything completely wrong with the A300-600 design, it would have been found out long ago, by other operators.

Sadly, AA was the first...with good reason, IMO.

The facts really do speak for themselves...that is, to anyone objective enough to actually read the NTSB findings.
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Old 14th Dec 2004, 00:57
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This maybe trivial, concerning the Cali accident. Was there not a discovery that in the Honeywell FMC database there were actually TWO different fixes, both having the exact same idents as Tulua, which was near the Cali airport? Read this years ago in "Aviation Week" after I was in 757 training. One was near the airport and the other was off in a totally different direction, yet the FMC turned the airplane towards the mountains!

This is not to excuse the crew's rush to change runways in a plane which is very difficult to slow down, even with flaps 5 and speedbrakes extended, while descending (talk to crews who flew the old LAX Civet Arrival ), and allowing the plane to turn off into the darkness from a charted route. The 757's speedbrakes make almost no noise or vibration in the c@ckp1t/flightdeck, and are out so often that in a very high workload situation, you almost need to leave your hand on the lever in order not to forget.

But I never was/will be the type, so common on Pprune, who can always avoid making mistakes .
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Old 14th Dec 2004, 02:57
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Indeed it was, Ignition Override, the designator was 'R' as I recall, and it was off somewhere in Brazil, in their database.

Now, if you are heading in the proper general direction, and you enter what you think is the proper ID, yet the aeroplane turns to left field, can this really be that hard to miss?

Modern electronic FMC's are fine, and can indeed be a real help, but on the other hand, basic instrument flying techniques have to enter the picture at some point, and for these AA folks, it just simply did not.

Pilots need a good deal of situational awareness, yet it was absent on that dark night at Cali, by both guys at the pointy end, so bang, into the hill.

One would think that AA pilots are better than this...sadly not.
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Old 14th Dec 2004, 04:34
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Question

411: I agree with most if not all of your objective facts and data on various topics, but because accidents have happened throughout airline history due to loss of situational awareness (whether the non-flying pilots clearly expressed a concern or not), must it be constantly emphasized that American's training and procedures are really much worse than elsewhere? If one seriously questions AMRs overall flight ops. and mgmt attitudes about safety (versus revenue/"mission-oriented" accomplishment), then is this done from a detached, quite impersonal perspective, with no personal bias at all? One of the largest US airlines with a high percentage of short-haul flights, statistically, can experience a certain share of incidents, no matter what the safety culture. Is this not true, if all else is equal? I'm not trying to make any excuses for accidents, however our industry is full of pilot furloughs, downgrades, even upgrades and various levels of requal training syllabi (very short, medium or long course), right now. These can influence safety, and not just in subjective ways. Some of our industry's requal and line check training might consist of barely enough simulator periods, due to cost management. These are some factors at some US majors.

At least one regional airline flying the CRJ has hired some pilots who have only about 500 hours 'experience', because more experienced pilots can not afford, or simply refuse to go through weeks of training while being paid NOTHING. One of 'their' Line Check Airman told me so at an airport Taco Bell, near gate 70.

If AMR's insurance company went over their flight operations with a fine tooth comb, as supposedly happened at another US company's flight ops very recently (due to several hull losses, both wide and narrowbodies), then this would indicate a very unfortunate trend. But is that the case? A complex situation can not be described or resolved with oversimplified, sweeping generalizations. A detailed investigation is needed to understand various elements.

I leave these as open questions for all readers of these topics.

Last edited by Ignition Override; 15th Dec 2004 at 04:52.
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Old 14th Dec 2004, 05:17
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Well, Ignition Override, I cannot argue with much that you say.
Certainly, training today is at a minimum in many companies, and by minimum, I mean the very least that they can get by with, and still satisfy the regulations.
Which sometimes ain't much...that is truly needed.
When I went onto jets for the first time (B707) the program called for thirty two hours of sim followed by 10 hours in the aircraft, as the sim was not approved for many maneuvers then (or now) required.
This was for a direct entry Command, which was my situation at the time...directly into the left seat.
Yes, I was lucky, and the company I was working for at the time needed Captains...pronto.
So, I presented myself at PanAmericans door, and at the end, a new 707 Captain emerged...at age 30.
Then, off to Africa, with old PanAmerican and TWA straight-pipe 707's, Doppler navigation, NDB approaches (no ILS's in sight, except at LIS) and plenty of long flying hours...with minimum rest in between.
Thanks to old line Flight Engineers, I learned from the school of hard knocks, and didn't crash...fortunately.
Then off to bigger and better things.
Always with minimal recurrent training during those years with the charter companies, until moving up the ladder with a large scheduled carrier.
And, when I arrived at that large scheduled carrier, I found that they were precisely interested because of my rather varied experience, and in their opinion of the knowlledge that I could pass along to new First Officers...who, oddly enough, came to the 707 with a total number of flying hours that was less than 300, yet these folks never crashed and went on to become rather senior Captains.
Gosh, what a surprise.
Yet at American Airlines, a very old line company, with several thousand pilots, and a lot of flying experience under their belt, continue to have some very basic errors with their flying procedures, something I would have hoped would have been eradicated long ago.
But it apparently is not to be.

Looking at AA objectively, you gotta admit, something is wrong in Dallas...and it ain't the cowboys.
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Old 14th Dec 2004, 17:07
  #39 (permalink)  
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Wow it sounds very impressive !!!

Perhaps the CV is next.

Ignition and PRAAM
don't you see the point?

The guy is most probably looking for
a simulator instructor job with AA.

Maybe you should ask him for an interview.
 
Old 14th Dec 2004, 19:12
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Talking

If I could trust him to find his way to Ft Worth and not Ft Wayne, or even Yorkshire, I probably would....but he'd have to pass my Flight Test first. I doubt he'd make it. Clearly lacking in basic navigational and social skills.... Clearly muddled between rudder hardovers and structural failure.

What we used to call in the RAF an utter pr@t....the sort of person who used to stand in the corner of the Mess regailing all the bored jp's about his hero status and flying skills. Yawn...

Some people never learn, blah blah....

Something smells, blah blah....( I think it's his Depends...)

blah blah blah
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