C-5 accident at Dover AFB
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Completely idiotic of the crew to have raised the flaps below Vref speed.
Completely idiotic of the crew not to have instinctively shoved all throttles to their forward stops during the airspeed decay below Vref and during the stick shaker warning and subsequent voice generated "stall" warning.
These crewmembers should be given a dishonorable discharge from the Service for needlessly trashing an airframe and wasting hard earned taxpayers' money. A 3-engine approach is a non-event.
Completely idiotic of the crew not to have instinctively shoved all throttles to their forward stops during the airspeed decay below Vref and during the stick shaker warning and subsequent voice generated "stall" warning.
These crewmembers should be given a dishonorable discharge from the Service for needlessly trashing an airframe and wasting hard earned taxpayers' money. A 3-engine approach is a non-event.
The only possible explanation for such obvious lake of CRM, airmanship, knowing what you were doing, call it what you will is that the crew must all have been half asleep. Were they? If so, why??
I must have flown and assessed hundreds of 2-e inop approaches in aircraft and simulators in my old job. On not one occasion did anyone crash. Why? Good teaching, adequate practice, disciplined professionalism and consummate CRM. I'm not saying that any of this was missing at Dover, but unless the crew were completely fatigued so that they were incapable of performing to even a basic, adequate standard then it's difficult to draw any other conclusion.
"FULL POWER" - did any of the crew say that at any stage of the approach? If not, why not??
I must have flown and assessed hundreds of 2-e inop approaches in aircraft and simulators in my old job. On not one occasion did anyone crash. Why? Good teaching, adequate practice, disciplined professionalism and consummate CRM. I'm not saying that any of this was missing at Dover, but unless the crew were completely fatigued so that they were incapable of performing to even a basic, adequate standard then it's difficult to draw any other conclusion.
"FULL POWER" - did any of the crew say that at any stage of the approach? If not, why not??
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Seems to me, JW411, that BEagle has it right, FULL POWER was indeed required.
That it apparently was not applied in a timely manner, would seem to indicate inadequate training...or even worse, NOT PAYING ATTENTION!
Reserve status has positively no bearing on the matter.
EITHER, do it right, or suffer the grief later.
It really is that basic.
That it apparently was not applied in a timely manner, would seem to indicate inadequate training...or even worse, NOT PAYING ATTENTION!
Reserve status has positively no bearing on the matter.
EITHER, do it right, or suffer the grief later.
It really is that basic.
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I have no idea how the thrust levers and systems work on the C5A but on the B744 that I fly, after the problem engine has been positively identified and the shut down drills and QRH have been completed, we then go back to using all four thrust levers. The reason for this is precisely to avoid the kind of mishap we have seen in this incident.
As I mentioned, I have no knowledge of the C5A systems but does it preclude them using ALL thrust levers after shutting an engine down because of say a microswitch setup in the thrust lever quadrant or some other obscure reason? If not, then surely it is a failure of the training system that prevents the crew from using all four thrust levers even if one or two engines have been rendered inoperative. The fact that the crew didn't notice their mistake may be more than just a lack of attention as I'm sure they had no intention of crashing at the time and contributory factors may be ergonomics as well as poor training in technique.
Anybody know where the data recorder animation is available?
As I mentioned, I have no knowledge of the C5A systems but does it preclude them using ALL thrust levers after shutting an engine down because of say a microswitch setup in the thrust lever quadrant or some other obscure reason? If not, then surely it is a failure of the training system that prevents the crew from using all four thrust levers even if one or two engines have been rendered inoperative. The fact that the crew didn't notice their mistake may be more than just a lack of attention as I'm sure they had no intention of crashing at the time and contributory factors may be ergonomics as well as poor training in technique.
Anybody know where the data recorder animation is available?
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By the numbers now...
Lets see, from left to right, 1,2,3,4.
Seems pretty simple to me.
You simply don't NEED to move any throttle that is connected to an engine that has been shutdown.
IF you DO, then I would suspect a difficiency in training.
Considering that this was the USAF in action, it doesn't surprise me in the slightest.
Get a grip guys.
Move the throttle that is connected to an engine that is actually producing thrust.
Good grief...if this can't be properly understood, these folks had NO business WHATSOEVER being in the airplane concerned.
IE, don't send boys to do a mans work.
And, lets face it, these folks in the concerned C-5 were totally out to lunch on this particular day.
Seems pretty simple to me.
You simply don't NEED to move any throttle that is connected to an engine that has been shutdown.
IF you DO, then I would suspect a difficiency in training.
Considering that this was the USAF in action, it doesn't surprise me in the slightest.
Get a grip guys.
Move the throttle that is connected to an engine that is actually producing thrust.
Good grief...if this can't be properly understood, these folks had NO business WHATSOEVER being in the airplane concerned.
IE, don't send boys to do a mans work.
And, lets face it, these folks in the concerned C-5 were totally out to lunch on this particular day.
How about in a twin-turbofan plane?
After an engine fails or needs to be shutdown, the follow up procedures require use of BOTH throttle levers. This allows a certain lever to help retract ground spoilers when pushed to the go-around position, along with having the go-around (TOGA in some planes) button within reach of your thumb for the flight director, along with the throttles both being forward and they prevent unnecessary gear warnings from distracting you even more, during a go-around etc. And both reverser buckets open, allowing more drag after landing. About four extra reasons to use both throttles.
And the operative engine's lever is always in your hand, when needed, preventing a gigantic mistake, as happened on the C-5.
The C-5 has been around far too many years for their Initial Training syllabus not to have one standard way to operate the throttles and prevent a catstrophe.
Some 4-engine jets must not need these extra features? Would operation of the throttle which had a faulty reverser seriously affect controllability on the ground after the engine is shutdown?
My sympathy goes out to everybody who was on that plane.
Serious fatigue can be very insidious and I can't imagine how any pilot or FE can always be immune to it.
After an engine fails or needs to be shutdown, the follow up procedures require use of BOTH throttle levers. This allows a certain lever to help retract ground spoilers when pushed to the go-around position, along with having the go-around (TOGA in some planes) button within reach of your thumb for the flight director, along with the throttles both being forward and they prevent unnecessary gear warnings from distracting you even more, during a go-around etc. And both reverser buckets open, allowing more drag after landing. About four extra reasons to use both throttles.
And the operative engine's lever is always in your hand, when needed, preventing a gigantic mistake, as happened on the C-5.
The C-5 has been around far too many years for their Initial Training syllabus not to have one standard way to operate the throttles and prevent a catstrophe.
Some 4-engine jets must not need these extra features? Would operation of the throttle which had a faulty reverser seriously affect controllability on the ground after the engine is shutdown?
My sympathy goes out to everybody who was on that plane.
Serious fatigue can be very insidious and I can't imagine how any pilot or FE can always be immune to it.
Cargo Boy was entirely correct. I flew for two DC-8 operators prior to flying the B744, which I fly now. In all cases, once a failed engine is secured, you use all the throttles. 411A, there is simply no good reason not to use all four. It would have prevented this accident, and its a lot easier on the hand then trying to fool around with three throttles out of four. I've seen the animation, and its sad to watch. They've even marked the event when the throttles come back up as "throttle swap". Thank God there was no post crash fire and everybody survived.
411A you're painting the US Air Force with a bit of a broad brush. I'm not ex-military, but I've flown with guys from all the branches of the US military as well as guys from all over the world. I've seen good and bad from all backgrounds, and the Air Force guys I've flown with have been just as good as the civilians and those from other nations' Air Forces. So give it a rest, eh?
411A you're painting the US Air Force with a bit of a broad brush. I'm not ex-military, but I've flown with guys from all the branches of the US military as well as guys from all over the world. I've seen good and bad from all backgrounds, and the Air Force guys I've flown with have been just as good as the civilians and those from other nations' Air Forces. So give it a rest, eh?
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Oh for heavens sake! 411A, we all know you were gods gift to aviation and never did any wrong but please, spare us your sanctimonious thoughts on how you could never make any mistakes because you were so perfect. Thankfully you are not in a position to bore some poor beginner in real life with your know-it-all, Pythonesque style of "in my day we did it like..."
We try to learn from errors in this business and we do it without a blame culture that you so obviously need in order to satisfy your pathetic, boring life that you are now, thankfully, not inhabiting the cockpit of a 'modern' airliner. Yes, we all know you can count to four but that doesn't mean that you have to make life more difficult for yourself or your colleague just because you feel the macho-like need to express how clever you are. If it can be simplified by using all thrust levers after the appropriate engine has been shut down then you should train pilots to do it that way, subject to systems differences.
We try to learn from errors in this business and we do it without a blame culture that you so obviously need in order to satisfy your pathetic, boring life that you are now, thankfully, not inhabiting the cockpit of a 'modern' airliner. Yes, we all know you can count to four but that doesn't mean that you have to make life more difficult for yourself or your colleague just because you feel the macho-like need to express how clever you are. If it can be simplified by using all thrust levers after the appropriate engine has been shut down then you should train pilots to do it that way, subject to systems differences.
So they left the throttle for a good engine down.
So how is it that none of the bodies in the cockpit noticed the engine gauges showing power out of only two?
Possible factors include fatigue, display design and group dynamics.
So how is it that none of the bodies in the cockpit noticed the engine gauges showing power out of only two?
Possible factors include fatigue, display design and group dynamics.
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>>If it can be simplified by using all thrust levers after the appropriate engine has been shut down then you should train pilots to do it that way, subject to systems differences.<<
Sorry to disagree with you, 8driver, but where I was first trained on four engine types, inop engine throttles were left at the idle position.
This was not just in jets either, 4 engine turboprops and pistons as well.
IF a pilot cannot understand and use the remaining operative engines in a suitable manner, they have no business whatsoever on the FD.
Period.
Sorry to disagree with you, 8driver, but where I was first trained on four engine types, inop engine throttles were left at the idle position.
This was not just in jets either, 4 engine turboprops and pistons as well.
IF a pilot cannot understand and use the remaining operative engines in a suitable manner, they have no business whatsoever on the FD.
Period.
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True, true, true...411A. But if the guys are suffering from sensory overload as these sorry Billy Goats apparently were, then if there's the slightest doubt about which engine was or wasn't on vacation, then it wouldn't hurt to shove all the throttles to their forward stops.
I am involved with training on a 4-engined aircraft. We retard the throttle of an engine that has been shut-down and then do not move it. The only reason I can offer is that the approach procedure is very benign and this practice reminds crew that they are on 3 engines. Our procedures have been in use since the 1960s and I don't believe that there has ever been a problem of "throttle swap". However, I can see the validity in moving all 4 levers and will raise the subject with my colleagues.
Returning to this specific case - in my experience the great majority of 3-engine approaches for training take place with an outboard engine "failed" - as it is a more demanding handling exercise. It strikes me that it would be more likely that a tired crew could mix-up the inboard throttles than an outboard/inboard, particularly if their training usually takes place with an outboard retarded. I agree that it seems incredible that the crew did not see their error on the engine instruments - but perhaps this is where the adequacy of their training on a new flight deck should be examined. I remember exactly the same problem being a raised as a factor in the Kegworth 737 crash, where a crew that were used to the analogue -200 layout confused some instrumentation in the glass -300.
Even in the worst cases of crew error there is usually some form of deficiency in training or supervision.
Returning to this specific case - in my experience the great majority of 3-engine approaches for training take place with an outboard engine "failed" - as it is a more demanding handling exercise. It strikes me that it would be more likely that a tired crew could mix-up the inboard throttles than an outboard/inboard, particularly if their training usually takes place with an outboard retarded. I agree that it seems incredible that the crew did not see their error on the engine instruments - but perhaps this is where the adequacy of their training on a new flight deck should be examined. I remember exactly the same problem being a raised as a factor in the Kegworth 737 crash, where a crew that were used to the analogue -200 layout confused some instrumentation in the glass -300.
Even in the worst cases of crew error there is usually some form of deficiency in training or supervision.
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The design of the C-5 cockpit, especially the throttle position, does not strike me as one that invites the FE to get involved too much in what goes on in the front. I don't know what the glass version looks like, but inless the engine instruments are displayed more prominently than in the analogue version, I can see how this could happen.
I agree with 411. Leave the dead engine's throttle in idle. If the remaining engines have to come back to idle, the FE should have a finger on the dead throttle when they are advanced again. Basic stuff really.
I agree with 411. Leave the dead engine's throttle in idle. If the remaining engines have to come back to idle, the FE should have a finger on the dead throttle when they are advanced again. Basic stuff really.
The theory of using all four throttles when an engine has been shut down is all well and good if you happen to fly an aircraft where the fuel is switched off using a separate lever (does anyone else remember HP and LP cocks?). However some aircraft have a single lever system where fuel off is achieved by pulling the throttle right back through the FI/GI detents.
On such aircraft using all four throttles would allow fuel to flow again to the engine which has already been shut down and this might not be a smart thing to do. For the last 20 years I have been flying such an aircraft and I have never seen the wrong throttle being left behind.
Why should this crew have been fatigued? It is my understanding that they were setting off from Dover AFB to Frankfurt and at the beginning of a duty?
Mind you, if it was a Reserve crew they might well have been flying their ars*s off doing something else in their day jobs.
On such aircraft using all four throttles would allow fuel to flow again to the engine which has already been shut down and this might not be a smart thing to do. For the last 20 years I have been flying such an aircraft and I have never seen the wrong throttle being left behind.
Why should this crew have been fatigued? It is my understanding that they were setting off from Dover AFB to Frankfurt and at the beginning of a duty?
Mind you, if it was a Reserve crew they might well have been flying their ars*s off doing something else in their day jobs.
JW411 I don't believe the C-5 has throttles of the type to which you refer, although I may be wrong.
Lets give an example from the B744. The autothrottle disconnect switches are outboard of numbers one and four. How would I easily access those switches with my thumb (as it is designed) if number one was left retarded and I am flying from the left seat, or number four is retarded and I am flying from the right seat? Assholes and elbows.
So far a number of good reasons have been given for using all the throttles when an inoperative engine is secured, not the least of which is that it would have avoided this accident. All I've heard in reply is "you should be good enough to remember which engine is shut down!", and that's not a good enough reason for me! (JW411s example as an exception). I wonder how they do it on the B-52, where they have 8 to deal with? Any BUFF drivers out there?
So anyway 411A, since you've got this down pat, on a B744 why would you leave an inop throttle closed, especially with perfectly good TOGA switches on 2 and 3, and autothrottle disconnect switches on 1 and 4? Any sensible reason will do.
Lets give an example from the B744. The autothrottle disconnect switches are outboard of numbers one and four. How would I easily access those switches with my thumb (as it is designed) if number one was left retarded and I am flying from the left seat, or number four is retarded and I am flying from the right seat? Assholes and elbows.
So far a number of good reasons have been given for using all the throttles when an inoperative engine is secured, not the least of which is that it would have avoided this accident. All I've heard in reply is "you should be good enough to remember which engine is shut down!", and that's not a good enough reason for me! (JW411s example as an exception). I wonder how they do it on the B-52, where they have 8 to deal with? Any BUFF drivers out there?
So anyway 411A, since you've got this down pat, on a B744 why would you leave an inop throttle closed, especially with perfectly good TOGA switches on 2 and 3, and autothrottle disconnect switches on 1 and 4? Any sensible reason will do.
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Quite simple, 8driver, you don't use the autothrottle in these situations.
I have seen it time and again in the sim, guys using the autothrottle with engines shut down, in many cases the result is poor performance.
Now, as I don't fly the 744, I wouldn't know about that type, however my experience indicates (in other types) that the handling pilot had damn well better know which engines are operating, and which are not.
Otherwise, he belongs in a ground job.
Automation is fine, up to a point.
However, at some point in time, you have to realise that the handling pilot has to be in the loop, otherwise accidents occur.
Just like this very unfortunate one.
It seems everyone in the C-5 was asleep at the switch.
How very sad.
I have seen it time and again in the sim, guys using the autothrottle with engines shut down, in many cases the result is poor performance.
Now, as I don't fly the 744, I wouldn't know about that type, however my experience indicates (in other types) that the handling pilot had damn well better know which engines are operating, and which are not.
Otherwise, he belongs in a ground job.
Automation is fine, up to a point.
However, at some point in time, you have to realise that the handling pilot has to be in the loop, otherwise accidents occur.
Just like this very unfortunate one.
It seems everyone in the C-5 was asleep at the switch.
How very sad.