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Indonesian B737 runway overrun/crash

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Old 8th Mar 2007, 22:21
  #121 (permalink)  
The Reverend
 
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There are a lot of "expert" opinions here that need correcting. The Shadow please note:
This apparently happened three times and on the third occasion the nosewheel oleo snapped off (thereafter no hydraulics, no nosewheel steering, no directional control via rudder, no reverse and MLG braking only from the brake accumulator - about five applications before it's empty).
The 737 has two independent hydraulic systems "A" and "B". Even if system A was completely lost when the nose gear sheared off,(nosewheel steering was no longer of interest) Rudder, No.2 Thrust Reverser and Normal Brake system still powered by sys. B.
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Old 8th Mar 2007, 23:43
  #122 (permalink)  
 
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Ultralights,
(warning: guess hazard)The 734 has something what I call "partial trim assist", dunno the real term for it... ie. if you pull the nose up, there will be some up trim to assist the elevator, and the same for "down"... However of you have that trim we see on the photo, it's one heck of a low trim.

If we may guess, the last significant yoke movement before any off runway impact was down. The yoke up is possibly (warning: guess hazard) a result of yoke displacement or cable distortion due to the ground impact.

The flap does not seem to be flap 30...

---

Sinbad1,
I checked with an F/A on the 737 on why the slide wasn't deployed, she said, they need to assess the situation whether the slide would assist or hamper the evac. According to their manual (this is not from GA btw), for after impact land emergency...
1. Remain in brace pos until complete stop. Several impacts possible
2. Turn on Emergency Light (L1 position) {FA comment: This may not have been possible looking from the vid}
3. Wait for Command from Cockpit, if no word, if situation requires evac, initiate evac.
4. Shout emergency commands (edited)
5. If pax panic, shout assertive commands (edited)
6. Assess condition, feel for heat and look out window. Look for fire or obvious structural damage that could be hazardous for slide/raft deployment.
7. If exit is usable, open door.
(remainder of list is edited).

Now she commented, if you see obstacles or severe fire hazard, you do NOT inflate the slide. Now looking at http://www2.indoflyer.net/botak/montage2.jpg there was the RIGHT wing ONTOP of the LEFT wing, I asked the F/A, if you see that, would you deploy the slide? Answer, No, if that catches fire, you're in trouble because it could give fuel to feed the fire even nearer to the door, hence blocking your last few exits. So, after seeing outside, you disarm the slide and open the door. Hence the "slide armed tape" is still hanging.
---

but does raise the question of finding a longer runway.
That seems to be the case, but we have to wait for confirmation. A flap assymetry on/near final approach does not seem to be a reason to declare emergency. That is a judgement call for the PIC to continue, or divert. Given that the nearest alternative is 50NM away and runway length is 400m longer than JOG, and the nearest longer runway after that is Surabaya (40mins - 1hr under normal conditions, which diverting there with flap assymetry being a risky proposition in terms of fuel burn, giving you an even less choice of actions upon the ultimate approach), he had to make a decision, "is it possible to land in JOG with whatever I have left?"... Flap15 at MLW and max man brakes under 2200m, able... go for it. Now whether that was the right call to make, we'll let Garuda and the NTSC decide... bear in mind hindsight is always 20/20. If the "land long" was caused by a flap15 landing using a flap30 flare technique, well, that could explain a lot... but again, we have to wait and see.

---

This apparently happened three times and on the third occasion the nosewheel oleo snapped off (thereafter no hydraulics, no nosewheel steering, no directional control via rudder, no reverse and MLG braking only from the brake accumulator - about five applications before it's empty).
Does this: http://www2.indoflyer.net/botak/nosewheel.jpg
Look like the oleo snapped off? I've to see the pics of what part of the nosegear they found on the airport perimeter, but I am told that it is the wheels that had come loose, not the landing gear oleo.

Back to porpoising. Adding to these self-wrought woes is the fact that any power "adds" (or throttle manipulation) will inhibit spoiler extension and add to the overrun likelihood.
Well, airside eyewitnesses stated spoilers and reversers deployed, nosegear contacted runway with the wheels absent hence the sparks.

---
Theamrad,
Well, high sink rate and downdraft report could be a result of confusion due to severe emotional stress clouding one's memory. But, logically, chasing an ILS at 170 knots-ish comparing with 140, would yield a higher sink rate... and also give the visual impression to those on the ground that he was high and fast. For all we know, he could have been on slope... need the FDRs for that.

ATC reports wind as calm, but, seeing the video of the post evac, we can see there's a 5-10kt breeze... and some estimates up to 15kt. Colleagues from JOG did specify that wind that night was "unusual", but by the morning it was as we saw in the vid. Now given JOG, it wouldn't surprise me if the wind at 500'AGL would be a totally different story... thanks to the terrain.
---
Flight conditions appeared normal until the aircraft was about 1000 feet above the Yogyakarta's runway, Captain Komar and his co-pilot told Captain Stephanus yesterday.
We need to determine whether "flight conditions normal until about 1000ft above" was the aircraft config, or the handling of the aircraft, which would be explained by (but needs a look into), the wind and the surrounding terrain, oe other the flap itself?

but I cannot see how the pilot would have been doing this, especially when the cockpit section ended up separating from the rest of the fuselage.
Pls check the beginning of the video, with a mangled cockpit.. but still attached (and eyewitnesses said it was still attached prior to the fire taking over).
---

Finally got normal sleep last night...

PK-KAR
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Old 8th Mar 2007, 23:55
  #123 (permalink)  
 
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Hotdog, agreed.

Sinbad,
he would have been performing this landing to perfection and knowing the landing check list by heart.
So? Chuck Yeager still makes mistakes.
The problem could not have been flap asymmetry for two reasons
Where in your quote is flap asymmetry mentioned by the chief pilot? What about if they had selected the first stage of flap at say 10nm, it got stuck there, they upped the speed bugs for the reduced flap setting for landing and decided to continue, not knowing they were going to get hit with undershoot shear during the flare?
If the hard landing would have been the cause of such damage ( I think not) you could only go back to Adam Air and see the difference.
So ALL hard landings result in Adam Air damage? I've been in a few hard landings that have resulted in a bounce/s but the jet hasn't broken apart!
I think the Cabin Crew did a magnificent job under the circumstances, but I cannot see how the pilot would have been doing this, especially when the cockpit section ended up separating from the rest of the fuselage.
It is quite conceivable, considering that both pilots survived, that they got out of the cockpit (if they were still in it) and went back to help the CC with the evacuation. In fact, it's probably in their SOPs to do so.

Dagger
a. Low time Right-seater flying and a quite experienced captain in the LHS being so distracted by the unstable approach that he doesn't lower any flap (normally a RH seater's duty).
Is it Garuda SOP for the right seater to select the flap?

For your information, GPWS, for years, has had a function which warns the crew if not landing at normal landing flap. I very much doubt if this Garuda 737 was not fitted with it. So landing with no flap at all is, to my mind, a complete furphy, unless the crew did it deliberately, which is just not practically believable.

I too come to these types of threads in an effort to learn something. Unfortunately, a worrying number of posts are just pure and utter speculation, full of red herrings, by people who appear to know nothing about what they are talking.

Last edited by Capn Bloggs; 9th Mar 2007 at 00:15.
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Old 9th Mar 2007, 00:27
  #124 (permalink)  
 
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Don't all you system experts forget that, if the aircraft is travelling fast enough, the flaps won't fully extend despite the fact that they have been selected and their operation is serviceable.

This prang joins a considerable list of such incidents at this airport.
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Old 9th Mar 2007, 00:57
  #125 (permalink)  
 
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The sad thing is there is no way an Airbus would have sheared off the nosegear and fallen apart like that. And Casper you could have taken full flap and the aircraft would have eventually given it to you when speed decreased appropriately.

Condolences to the families who have lost loved ones.
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Old 9th Mar 2007, 01:12
  #126 (permalink)  
 
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Is it Garuda SOP for the right seater to select the flap?
For the benefit of DaggerDirk,
PF calls, PM selects (and checks the indicator)
If PF doesn't call, PM recommends.
GA doesn't like F/Os who just sit there and follow the Cpt blindly anymore! The ones that are, gets FIRED.
For your information, GPWS, for years, has had a function which warns the crew if not landing at normal landing flap. I very much doubt if this Garuda 737 was not fitted with it. So landing with no flap at all is, to my mind, a complete furphy, unless the crew did it deliberately, which is just not practically believable.
There's video evidence somewhere with the GPWS installed on GA 737s, though not on this 737. It's ex JetAirways, ask JetAirways if they had 734s without GPWS. *grin*

The sad thing is there is no way an Airbus would have sheared off the nosegear and fallen apart like that.
Should I just laugh this one off?

Last edited by PK-KAR; 9th Mar 2007 at 01:40.
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Old 9th Mar 2007, 01:43
  #127 (permalink)  
 
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Don't all you system experts forget that, if the aircraft is travelling fast enough, the flaps won't fully extend despite the fact that they have been selected and their operation is serviceable.
True, but only over 160ish KIAS and then only from 40 back to 30 or 30 back to 25??

Re GPWS, if this aircraft was indeed not fitted with it, then that reflects (badly) on the regulatory authority.
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Old 9th Mar 2007, 01:58
  #128 (permalink)  
 
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The sad thing is there is no way an Airbus would have sheared off the nosegear and fallen apart like that.

WTF!! (All notions of self restraint thrown aside!!) Maybe (I hope) you havn't seen the embankment it collided with??

Maybe in the infamous LeBourget Airbus crash - the rest of the craft disentegrated, but the nose gear was still intact?
If there's no way the nose gear could shear of an Airbus try a search for the following:

March 10, 1997. A40-EM Airbus A320-212 Gulf Air
February 7, 2001. EC-HKJ Airbus A320-214 Iberia
October 26, 1999, VT-ESL Airbus A230-231 Indian Airlines
August 28, 2002. N635AW Airbus A320-231 America West

It's bizarre where the A vs. B thing pops up - i know which side I'm on - but usually try to refrain from joining in - appologies to those who it bugs.


Casper, I can only find one other event similar (runway excursion) to this one in reasonable near history - maybe you could enlighten me to the considerable other events.

Where in your quote is flap asymmetry mentioned by the chief pilot? What about if they had selected the first stage of flap at say 10nm, it got stuck there, they upped the speed bugs for the reduced flap setting for landing and decided to continue, not knowing they were going to get hit with undershoot shear during the flare?
Capn Bloggs, I believe there is a report of early flap difficulties, but that it was resolved (again reportedly). I think the scenario you suggest is a pretty reasonable possibility - leading to the dilema - what inadequate level of flap (and consequent increased speed/landing distance) would be acceptable vs. a divert to a longer runway ...... IF fuel with decreased performance adequate. If you put yourself in that situation, at a certain level of flap - distance is limiting and you've got to make the call of risk balancing. It also links in with PK-KAR's suggested possibility:"If the "land long" was caused by a flap15 landing using a flap30 flare technique, well, that could explain a lot... but again, we have to wait and see."
Altogether, would not be a nice situation.
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Old 9th Mar 2007, 03:44
  #129 (permalink)  
 
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Theamrad,
Casper, I can only find one other event similar (runway excursion) to this one in reasonable near history - maybe you could enlighten me to the considerable other events.
I found 2... 1 was a flap assym landing with no damage... Again, with a looong flare requiring speedbrakes to "ease the baby down"... used about the whole 3000m of runway.

The other, was a late flare on possibly flap15, again under flap assym... result was a write off. However details are not to be disclosed (coz I got it from a leak). If you want to check which one this one was, try the Lion Air 734 in Makassar (UPG/WAAA) in December.

Capn Bloggs, I believe there is a report of early flap difficulties, but that it was resolved (again reportedly). I think the scenario you suggest is a pretty reasonable possibility - leading to the dilema - what inadequate level of flap (and consequent increased speed/landing distance) would be acceptable vs. a divert to a longer runway ...... IF fuel with decreased performance adequate. If you put yourself in that situation, at a certain level of flap - distance is limiting and you've got to make the call of risk balancing.
Try this for the balancing act:
Just out of curiousity, if you're shooting an ILS, and then at 3500AGL (4000ft), 1 dot below glideslope you do the normal thing, gear down, and flap 15, then as you enter the slope, you want to go to the next setting, but then you found an assymetry... say at one wing at 15 and 20 on the other, there's 1 traffic being told to take off in front of you and he's gonna make a tight left turn to "downwind", the runway is 2200m, you're surrounding terrain is:
>2000ft 4NM after the runway, with 1000ft contour about 3NM from the other end of the runway
The terrain to your right is >2500ft extending to your 4 o'clock from your present position,
A mountain to your left where the 1000ft mark is 5NM to your left, and 2000ft at 10NM, thereafter rising rapidly to 10,000ft.
The only escape in front is to the front left at your 10.30
The nearest suitable runway longer than JOG is 400m longer, anything longer than that (3000M) is 250NM away... which is your alternate... over some "nice" terrain.

1. Would you land and risk it bear in mind traffic and terrain and try a max braking landing knowing that under max braking the numbers are OK?
2. Would you go around and re-prepare? (which is probably a good thing given the hindsight)
3. Or would you divert?
Bear in mind a go around on that approach under non-normal (assume Flap Assym) can out you in conflict with the departing traffic, or any of the surrounding terrain.

Remember, hindsight is 20/20... We need to know why he didn't! He might have had a damn good reason not to!

I don't see anything wrong with the approach should this be a flap15 under assym, the problem was the flare... by this time, there are a lot of IFs and COULD HAVE BEENs, the only 2 things are consistent: the runway remaining rapidly running out, and those damn hills at the other end!
---
Collar,
Wanna bet that the CVR would reveal otherwise?
1. We don't drink teh tarik here! That's Malaysia!
2. F/A entering F/D below 10,000 on GA would only be to report "Cabin ready"... and as far as I know, it is strictly applied.

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Old 9th Mar 2007, 06:02
  #130 (permalink)  
 
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Rather B Flying
I think in the air canada one the spoilers did not retract when go around power was applied , so they tried to fly with full ground spoiler deployed. Also as a result of this accident MDC later modified the spoiler systems so that they would retract when the throttles were advanced for a go around.
I Must say though its not looking too good for the pilots right now ...hope Im wrong
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Old 9th Mar 2007, 08:55
  #131 (permalink)  
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Wink Misunderstanding

Capn Bloggs "So? Chuck Yeager still makes mistakes."



I think you have misunderstood my posting big time. I was not having a dig at the flight crew, when I referred to the pilot knowing his landing by heart, I was trying to eliminate any mistake with regards to his landing calculation. After all the pilot has 22 years experience. Also looking at wreckage, the first question I asked "I wonder if the flight crew are alive?!" Believe me I was very happy to find out they survived. I was mainly saying how was it possible that the flight crew managed to help under the circumstances given the state of the wreckage?!! Obviously the pictures must have been taken after the fire have consumed most of the fuselage. When I saw the footage on Euronews and watching the Pax scrambling out of the aircraft I thought that was as close as you can get it. I have been working, advising and flying with pilots for decades, most of them are great, some are not so great. My personal well wishes goes to the recovering Pax, FLIGHT CREW, and of course the unknown heroes the cabin crew.

As far as the flap is concerned, this is not the first aircraft that may or may not suffer such condition. In fact the 747 classics and the 400 often suffer such incidents, especially after a hangar check due to rags left in the sailboat which obstructs the cable run. However, your point is valid with regards to the flap setting. My comments about asymmetry was in response to posts on PPRune (Porrohman page 6) and the fact that the captain of the Garuda flight told his chief pilot that he could not extend his flap (see Bear11 page 6).

With regards to the Hard Landing, NO not all aircraft suffer the Adam Air fate after hard landing (God knows how many hard landings I have inspected following inbound flight over the years), but if you read the statement coming out from the chief pilot, taking in to account the latest statement from the Civil Aviation Safety body of Indonesia in their finding evidence of debris left on the runway from the nose gear, the initial hard landing (and forgive me for saying this) would be on the main wheel first, not the nose wheel, would it not??

PK-KAR

Thank you for your explanation, When I said the slide was not deployed or armed , I was stating facts in reference to a post on this website and in no way I was criticising the cabin crew action. I know how hard those boys and girls work under normal circumstances, especially during a long haul flight let alone under crash conditions. The cabin crew as far as I am concerned are the real heroes of this terrible accident. I am sure all the crew followed the procedures as they saw fit.
 
Old 9th Mar 2007, 09:39
  #132 (permalink)  
 
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Sinbad1,
Sorry if you took it as a criticism of your post, I was trying to elaborate on your point using the procedures they used here. Sorry if it sounded "a bit defensive/offensive", but after reading several posts blaring out "tyro-type captains" and having "teh tarik" on final approach, restraint becomes a very precious asset. Sorry if I sounded as if I was criticizing you, wasn't the intention... it's been a loong few days over here. Flight cancellations, pax wanting refunds, almost loosing clients, family and friends all within a few days...

Yes they do work hard, some work so hard they get trodden allover, some love their work, some hate it, but at least most of them go about what they do as professional as they believe they can.

As for the cabin crew, I'm still trying to verify the last actions of the FA1 who died on duty...

Interestingly, all the cabin crew on that flight are seniors! Perhaps that too was a factor.

With regards to the Hard Landing, NO not all aircraft suffer the Adam Air fate after hard landing (God knows how many hard landings I have inspected following inbound flight over the years), but if you read the statement coming out from the chief pilot, taking in to account the latest statement from the Civil Aviation Safety body of Indonesia in their finding evidence of debris left on the runway from the nose gear, the initial hard landing (and forgive me for saying this) would be on the main wheel first, not the nose wheel, would it not??
Still trying to sift through some details of recollections of my friends of some eyewitnesses. They mostly concur with main landing gear first on the first bounce, but everything after that was blurry (apart from "it bounced 2x") until the point spoilers and reversers were deployed, at which point everyone was in utter disbelief, coz what they expected and feared most next, happened!

PK-KAR
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Old 9th Mar 2007, 10:36
  #133 (permalink)  
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Unhappy PK-KAR - no offence taken

Dear PK-KAR, Thank you for your humility. I assure you no offence was taken. I take it you work for the company. It must be a terrible time for all. As for the bounce, normally when an aircraft comes hard and bounces, especially the nose gear, tends to have a recoil action which means the oleo leg compresses and bounces off the ground and could cause the geometry downlock to break, and that would collapse the nose gear for sure.
If you remember last year Lufthansa 747-400 collapsed its nose gear at the gate, Eva Air at Heathrow 747-400 and the Fokker 27 of SAS had oleo nose collapse. I think PPRune would have a picture of that in their archive.
As for the ground spoiler getting fully deployed, on the 737 they have on the right hand main gear a cable called "ground spoiler interlock" which as soon as the undercarriage hits the tarmac, it actuates the ground spoiler immediately, and the thrust reverser action is purely pilot command.
Finally, I sincerely feel for all of you guys and hope some lessons come out of this terrible tragedy.
 
Old 9th Mar 2007, 11:27
  #134 (permalink)  
 
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Sinbad1,
No I do not work for the company.
Right now we're hoping that the investigation will not be interfered.

PK-KAR
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Old 9th Mar 2007, 11:31
  #135 (permalink)  
 
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Hi All, just in ref to the Air Canada DC-8 YYZ accident, the jet hit the rwy so hard it shed one or more engines, it did get airborne again but only really under little control. Sad accident for my family, it killed one of my Dad's best friends...he was the Capt... Sorry for the families and crews in Indonesia...hope the truth can be found soon.
LC
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Old 9th Mar 2007, 15:31
  #136 (permalink)  
 
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FA1

PK-KAR

Am advised that FA1 exited the aircraft after helping people out, he was seen on the video returning to the aircraft twice to further help/carry people out.

Sadly on the last return to the aircraft....... he did not reappear.......

A brave purser who sadly lost his life helping his passengers........
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Old 9th Mar 2007, 18:05
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PK-KAR, while perceptions have been mentioned a few times already – it is of course fair to say that sometimes perceptions (pilot or otherwise) can be larger than reality. A problem with flap asymmetry or failure to drive past a certain position should arguably not be a ‘critical’ event in itself. I would suggest the same would be true of a ‘downdraught’ encounter at 1,000’ AGL (if not a fully-fledged microburst!). But then IF one occurred after the other – an already heightened stress level could hit the overload level, and radically alter the ability to make the ‘right’ decision. I say that not as a criticism of this crew – but more as a remark on our sometimes frail human nature. ‘Human factors’ experts tell us that we are more likely to stick to a decision we have made, even after the information on which that decision has altered significantly, then reappraise the situation and alter our initial decision. Of course, accident reports and human performance of pilot action is done in the “cold light of day” through 20/20 hindsight goggles. I think there are a good few examples where pilots were criticised for their actions – with the benefit of hindsight….when the more reasonable would admit they would do the same thing under those circumstances…….There, but for the grace of God, go I!! etc.

Whatever the leadup here – like I said before, luck can play a major roll. Nice long stopway or nice level field of grass versus road, depression and embankment = completely different outcome……more’s the pity.

If I try to ignore hindsight – and put myself at the pointy end of the stick - as far as that balancing act is concerned – the major unknowns in my mind would be fuel remaining (Garuda SOP’s and specifics for that route?) and hydraulic status. Diversion of 50nm for 400m extra or 250nm for 3000m runway – I think I’d be biased against. Including the terrain/traffic complications you’ve outlined - as for the other 2 choices :

If hydraulic system failure (separate from or associated with) asymmetric flap – that would seriously influence my decision (While strict adherence to checklists (non-normal) is nice and for the most part essential – I believe, like some others, it shouldn’t override the use of ‘good judgement’)……. I don’t think I’d go for MA and extra time with control potentially a problem or with reduced authority. I’d be going for landing as soon as possible.
If flap asymmetry alone, hydraulics ok and controllability not badly affected – I’d take the MA and extra time option. With that scenario – there’s bound to be a certain “startle” element (especially IF speed reduction/flap extension was on the late side anyway), and personally I’d be glad to take the extra time if at all possible. Obviously there would be a stern self briefing and same for F/O about t/d on the first available asphalt being supercritical.

This is what I think my personal decision process would be – but of course, I admit, I’m not under the stress of being “at the pointy end” and we are dealing in the realms of possible scenarios / speculation.

Sinbad1

If you remember last year Lufthansa 747-400 collapsed its nose gear at the gate
Just out of curiosity – you know if there’s a source for more details about that?

I Must say though its not looking too good for the pilots right now ...hope Im wrong
I have to admit it seems that way to me – but I hope I’m wrong too. Hopefully the FDR/CVR details will paint a different picture.

Silberfuchs – I agree with what’s been said just above. I think this is just an expression along the lines of natural human emotion (as has happened in other events in which pilots understandably felt guilt – even though they were in no way responsible for an accident) and not in the sense of trying to imply any ‘liability’ on the part of the crew. Maybe Captain Stephanus is a bit naïve/innocent in comparison to how some of the media can sometimes twist things.


Anyone care to comment on whether the FDR details will be released to the public? Or kept quiet while investigation is ongoing? (Genuine question – NOT snipping!)

Last edited by theamrad; 9th Mar 2007 at 19:37. Reason: typo
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Old 9th Mar 2007, 18:17
  #138 (permalink)  
 
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The Lufthansa incident was LH760 in May 2006, the gear collapsed on pushback.

http://news.airwise.com/story/view/1147785921.html

http://www.forum.plane-mad.com/viewtopic.php?t=3851
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Old 9th Mar 2007, 18:54
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Thanks a lot, llondel - I'll take a look.
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Old 10th Mar 2007, 15:58
  #140 (permalink)  
 
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If the crew had some sort of flap issue, however minor during approach, would they not have informed someone as to the potential problem and request to have emergency crews standing by? From what I have read, nothing was mentioned. I would have thought with the possible higher speed (alleged) approach that an overrun was a possibility and having ground alert to this wise. What do SOP's require in this situation?
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