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kenya airlines 737-800 missing

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Old 28th Apr 2010, 10:36
  #361 (permalink)  
 
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That reminds me of my colleagues who died in the crash of the Saab340B of Crossair in Zürich. Did the Captain, in this case, chew too much Khat before the flight? Sad story.
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Old 28th Apr 2010, 10:58
  #362 (permalink)  
 
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The Crossair Saab went - to the best of my information - down because they had a Moldavian Crew Member who was PF - and the eastern Pilots were used to a different Artifical Horizon design (apparently western horizons have the plane fixed and ground moving, whereas eastern horizons have ground fixed and plane moving).

I don't know about eastern planes and training on them in Africa but would guess this was not a factor in the Cameroon crash.
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Old 28th Apr 2010, 12:00
  #363 (permalink)  
 
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EatMyShorts!,
A rather sad commentary on racial stereotyping don't you think?

Loosing spatial awareness seems to be the new way of committing industrial homicide with Flash Airlines, Ethiopian Airlines (suggested at this stage) and now Kenyan Airlines. I am sure there have been others.

Are we getting to the stage that pilots can no longer hand-fly on instruments? Do they have to have their hand held by the autopilot? Is airline training so concentrated on learning the automation that we have forgotten there is an aircraft to be flown.

This is basic stuff that should be bread-and-butter to an airline pilot. Isn't it time the slide in skills was addressed before more of this happens?
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Old 28th Apr 2010, 13:58
  #364 (permalink)  
 
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Disorientation comes in many forms and in many circumstances.
No one is immune; vulnerability varies with task proficiency and the commitment to manage personal attention when scanning instruments and systems. In addition, there can be human aspects including fatigue and previous experience; then there are (should be) defenses from team/crew aspects – cross monitoring and alerting.

Autoflight systems are ‘dumb but dutiful’; normally they will provide warning of failure or extreme manoeuvre, but a significant ‘communication’ weakness is that these depend on the system being engaged.
Handing control to another pilot can be confirmed with a “You have / I have control” routine, but autoflight systems don’t talk when engaged, sometimes they shout (warn), and they can bite. Thus correct engagement and initial operation must be checked visually and then announced stating active modes and anticipated changes (e.g. Autopilot engaged, Speed and Hdg; VOR and Alt armed).

It’s interesting to note different ‘safety cultures’ indicated by the media headlines – “Pilot error, Blame …” (NY Times) I wonder if the NTSB’s assistance used those terms, and the positive and professional view in “Poor airmanship” (Flight Global).
The latter offers hope of working on specific issues which can be improved - practice, attention management, knowledge, situation awareness (autoflight monitoring), and judgment (particularly of how and when to hand over control).

For other info see the visual guide ‘Understanding Spatial Disorientation’ at Aviation org – free registration for access to all of the library.
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Old 28th Apr 2010, 16:07
  #365 (permalink)  
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Report

It's a pretty large file due to the graphics included. Make sure you have lots of time and coffee.
http://www.ccaa.aero/images/blogs/d0...rt%20kenya.pdf
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Old 28th Apr 2010, 16:15
  #366 (permalink)  
 
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I'm not sure if that site is in cameroon or why it was slow to download. I suggest to be polite to the site and download the 40MB pdf only if intending to read it too.

The line proficiency checks of the captain highlited "performance deficiences". From the report:

- November 2002, route training assessment was converted to a training flight because the captain demonstrated inadequate knowledge of procedures and airline systems, including FMA, AFDS and fuel management.
- In July 2004 the captain went through route profiency training and check because of his decision to initiate diversion on scheduled passenger flight due to an standby ADI failure. this was seen as a indication of "lack of understanding airplane systems and redundancies that are built into the system."
- In August 2006 annual line check was judged to be below standard for a captain, leading to another check in november 2006

In the conclusions section:

32. The results of flight checks for technical flight personell were reported without any complacency, but not sufficiently exploited by operator.

Last edited by keitaidenwa; 28th Apr 2010 at 16:16. Reason: typo fix
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Old 28th Apr 2010, 16:57
  #367 (permalink)  
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including FMA
Bingo.

Live another day, check your FMA.....
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Old 28th Apr 2010, 19:32
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A copy of the report with OCR'd text embedded is available here:
http://busybee.dvv.org:8000/flying/rapport%20kenya.pdf

Last edited by dvv; 28th Apr 2010 at 19:51.
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Old 29th Apr 2010, 08:43
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Pilot Error Blamed for 2007 Kenya Crash That Killed 114

tourismandaviation.com
Ünal Başusta

The Boeing 737-800 airliner plunged into a mangrove swamp on a stormy night minutes after taking off from Douala, the west African nation's largest city, en route to Nairobi.

Pilot error and spatial disorientation during a thunderstorm was the probable cause for the crash of a Kenya Airways jet in Cameroon on May 5 2007, which killed all 114 people on board.

The crash report, compiled by the Cameroonian Civil Aviation Authority, found the captain didn't adhere to standard operating procedures and the plane took off without authorization from air traffic control.

Investigators have concluded that crew's poor airmanship was the reason for their not recognising and correcting an excessive bank angle during climb after take-off, leading to the crash.

After lifting off runway crew did not properly scan their instruments despite the lack of external visual references on a dark night. Due to their poor situational awareness they had spatial disorientation and failed to recognise the aircrafts slow banking to the right, which was initially corrected by the captain who was the flying pilot.

Some 42 seconds after the 737 became airborne the captain called 'OK, command'. While this signalled the activation of the autopilot, the autopilot did not engage and there was no confirmation of the autopilot's activation from the first officer, cockpit annunciator, or the behaviour of the aircraft. But the crew believed and acted as if "the autopilot was effectively engaged".

While they were dialing the right numbers for the heading select panel and altimeter, they both failed to recognise, from the instruments, the aircraft's increasing bank to the right. When they called for autopilot engagement the bank angle was already about 11°. Because they failed to engage the autopilot the bank angle continued to increase to 34° and a 'bank angle' warning sounded in the cockpit.

Untill that time they appeared to be "unaware" of the excessive bank angle and the auto pilot was not engaged. The captain expressed surprise at the alarm, and worsened the situation by first turning the control yoke to the right and thus increasing the bank angle more.

Then the captain became disorientated more, instead of trying to level off the plane manually he activated the autopilot first but at the same time handled the flight controls thus making autopilot unusable.

The right bank increased to 80°, after reaching a height of about 2,900ft, the aircraft pitched nose-down, banking eventually to 115°.

Flight-data recorder information indicates that, at one point, the two pilots were providing conflicting inputs to the aircraft's control column: the first officer was turning the control yoke left, with nose-down, while the captain was turning it right, with nose-up. That indicates none of crew recognised the true situation of the aircraft and were unable to give the right commands to make it recover at any time.

About 90 seconds into the flight, under those conflicting commands the aircraft banked beyond 90 degrees, descending into a downward roll, and the captain was heard saying ''we are crashing.'' Seconds later the 23 years old first officer mistakenly told the pilot to turn right, before correcting himself and saying "Left, left, left captain". The plane crashed nine seconds later, a minute and 42 seconds into the flight.

The report was posted early Wednesday on the website of the Cameroon Civil Aviation Authority (CCAA). Some of the investigation was conducted by the U.S. National Transportation Safety Board as well as Boeing experts in the United States and specialists in Washington and Pensacola regarding the effects of spatial disorientation.
"Spatial disorientation is a condition in which an aircraft pilot's perception of direction does not agree with reality".

Mr Maigari was the head of the Technical Commission that carried out investigations into the accident. The two black boxes -- one that records the flight data, and the cockpit voice recorder which records conversations between the captain, copilot and air trafic controllers -- were found on May 7 and June 9 respectively.

The CCAA cites a "lack of rigour" in piloting and It adds that the pilots' "inadequate operational control" and failure to co-ordinate contributed to the accident.

The report noted that the captain was 52 but that the first officer was only 23. Before takeoff the pilot admonished his first officer for turning on the plane's windshield wipers, and the report speculated that the first officer, already a shy person, did not speak up to tell the pilot about the aircraft banking when he should have because of their relationship.

The report said that the plane's manufacturer, Boeing, doesn't sufficiently explain rudder trim modifications due to temperature variations during climb and descent. But it added that the amount the plane was pulling to the right should have been easily correctable by the pilot.

Kenya Airways, which is 26 percent owned by Air France-KLM, said it had reservations over the report's findings that the pilot had not properly engaged the autopilot after take off. "One (reservation) is to do with the auto pilot, CRM (Crew Resources Management) and safety programme implementation," Titus Naikuni, the head of Kenya Airways, told reporters.

The report also said the Boeing flight manual did not include full information on the ability of the aircraft's autopilot to roll the airplane to a safe degree of banking from a dangerous level.

An aviation analyst in Nairobi said a total of 37 findings are expected in the report, 35 of which will have "direct relevance" to Kenya Airways.

The 114 people on board came from 26 nations, including an American AIDS expert who worked at Harvard University; businesspeople from China, India and South Africa; Cameroonian merchants; a U.N. refugee worker from Togo; and Briton Anthony Mitchell, a Nairobi-based correspondent for The Associated Press.

The investigation into the crash has been a long and difficult process. The plane went down in a mangrove swamp less than 6.5 kilometers from the runway, but it took officials 40 hours to find the plane. It took officials weeks to identify remains and there was a further delay before Cameroonian authorities released them to next of kin.

The wreckage indicated the plane flew nose-first into the ground. It was found buried deep in a crater of reddish-brown muck with only tiny bits of the rear fuselage and wings left above ground.

As a report into the Kenya Airway’s crash in Cameroon 2007 was released on Wednesday, it emerged that the lapse on the part of Kenya Civil Aviation Authority (KCAA) may see the national carrier pay higher insurance premiums.

Findings of a report of the crash indicate that chances of the crash occurring could have been averted, or significantly reduced, if Kenya Airways implemented its accident prevention system properly.

"KCAA failed to point out that Kenya Airways did not take into account the inefficiencies of the captain and the co-pilot during their evaluations by the company flight instructors," said the report.

"A number of operational procedures listed in the company’s operational manual were deviated from by the crew..."

Key among the concerns include the waiver of experience requirement for some of the pilots even after KQ signed to become part of international air travel agreements in 2007.

Prior to the flight, KCAA had waived the need for the co-pilot to have an experience of at least 150 flight hours, and three months of flight experience as laid down in the Kenya Airways operational manual provided by KCAA in line with international agreements.

"A waiver for requirement for utilisation of Flight Operations System had been introduced to satisfy operational demand," the report shows.

"These waivers were granted without adequate study on its safety implication."

Following the publishing of accident report, Kenya Airways is now staring at huge insurance premiums to cover its customers against accidents following revelations that the airline’s flight 507 crash had an element of human error. This move is likely grow the airline’s expenses and reduce profitability.

Experts say that a worst-case scenario may see Kenya Airways pay directly for compensation claims if the insurance provider cites the negligence clause on the part of the national carrier.

"If there is an element of human error as the report says, Kenya Airways may be in big trouble as it may be interpreted as negligence on its part on staff training and duties," said Peter Simani, an aviation lawyer.

"Another scenario is that of higher insurance premiums in future negotiations due to perceived risks as a result of the findings," he says.

Reports, pointing a laxity in implementing regulations due to personnel issues that should be addressed at Kenya Airways.

"KCAA will have to be strict in providing an implementing schedule as to how airlines recruit, train and promote their pilots and co-pilots but at the same time extend such programmes to their cabin crew," said Mr Simani.

Complete report;

http://www.ccaa.aero/images/blogs/d0...rt%20kenya.pdf
http://busybee.dvv.org000/flying/rapport%20kenya.pdf
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Old 29th Apr 2010, 09:15
  #370 (permalink)  
 
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Several paragraphs in that tourismandaviation.com report look oddly familiar...
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Old 29th Apr 2010, 13:19
  #371 (permalink)  
 
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pilot training history

OK lets have it someone,
What was the crew training background, and nationality?
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Old 29th Apr 2010, 14:55
  #372 (permalink)  
 
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Kenya Airways originally intended to temporarily employ foreign contract pilots to assist them through their period of rapid growth. This was rejected by the pilots' union, KALPA.
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Old 29th Apr 2010, 18:08
  #373 (permalink)  
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Why on earth are people still dying like this. Disgraceful.
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Old 29th Apr 2010, 18:48
  #374 (permalink)  
 
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I am interested in the similarities of this accident with that of the ‘Flash’ 737.
What was the aircraft instrument fit – EFIS; dials vs strip speed.
Are all the aircraft in the fleet similarly equipped?
When did the Airline / Crew convert to this instrument system
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Old 30th Apr 2010, 04:53
  #375 (permalink)  
 
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What was the aircraft instrument fit – EFIS; dials vs strip speed.
Are all the aircraft in the fleet similarly equipped?
When did the Airline / Crew convert to this instrument system
That is all irrelevant SafetyPee. This accident (like many recently) was caused by a lack of the fundamental skills that pilots should have nailed down by the time they have their instrument rating. It would be the equivalent of a surgeon not knowing how to scrub his hands properly before entering the OR, or a Chef not knowing how to make you an omelette.

You have no business in the cockpit of an airliner if you don't know how to:

- Fly on instruments
- Recover from an unusual attitude
- Properly manipulate the automatics

It is unfortunate, but this is what happens when you put commercial interests in front of safety concerns. Regulatory authorities are there to prevent corporate greed from putting passenger's lives at risk. In my view, the Kenyan regulatory authority is just as much to blame as Kenya Airways.

We need to make regulators responsible when they lower safety margins and an accident occurs. Otherwise, the situation won't ever change. Don't mean to pick on Kenya, this is happening all over the world as profits get bigger and will get worse with the continued decline of pilot numbers.
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Old 30th Apr 2010, 05:54
  #376 (permalink)  
 
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It also sounds like an over reliance on the automation. If you have an excessive bank angle the autopilot is not going to save you.

It's what you should learn in the first hours of flying - Fly the airplane first. Sort everything else out after.
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Old 30th Apr 2010, 07:32
  #377 (permalink)  
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fish

Haven't got time to trawl through whole thread, but I seem to remember that the Capt was ex military, accustomed to russian made fighters in which the horizons work opposite to western design, i.e. the airplane symbol moves around a fixed horizon.

If so, would explain inputs from Cap opposite to required, and conflict with cojo.

If not, I'll get me coat.
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Old 30th Apr 2010, 08:28
  #378 (permalink)  
 
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Tosh

The Kenyan Airforce has never flown East European/Soviet types. It has recently bought a handful of Chinese Harbin Y12 transports and Z9 choppers, but if the Capt had been with KQ for over 20 years he would only have flown Western types.
In fact, this accident is further evidence of a systemic and highly worrying lack of competence at KCAA, an organisation that is obsessed by following the letter of their hugely over-written bureaucracy while ignoring the intent and sense.
And of course, in the past few years Kenya has become one of the most endemically corrupt countries in Anglophone Africa.
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Old 30th Apr 2010, 10:01
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a few more important issues

On rotation the aircraft had a tendency to roll right. Captain maintained wings level by input of 30 degrees of left control wheel. Boeing talk about 6 degrees left control wheel to counter structural deviation.

So, why did the Captain have to input 30 degrees of left control wheel to keep the bank angle within the 3 degree limit? I do not blindly accept that rudder trim made up the difference somehow.

Also, only the boxes were taken from the wreckage, and everything else was left to be looted. There were suspected spoiler retraction issues with the SF version, and nothing in this report touched on this issue.

Thoughts?
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Old 30th Apr 2010, 14:59
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Yes , I was one of the intended LTCs needed by KQ 3 years ago , but rejected by KALPA ie strike threat , just wanted a 1 year contract , hopefully renewed if I was doing my job satisfactorily . Looking forward to ending my career where it started and giving something back , just wanted a fair wage .
Still love Kenya where I spent the first 28 years of my life , very disappointed that I was rejected out of hand .Not for me to say , but there has to be something unmentionable going on here ?
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