kenya airlines 737-800 missing

[safetypee]

Sqwak7700, Re #369.
I don’t exclude those contributions which you list; there are many others. However it could be short sighted to exclude other aspects which, although appearing to be irrelevant, might have contributed to this accident or should be consider in avoiding a future accident.

A significant contribution appears to be mis managed attention, perhaps due to over focus on weather radar and the avoidance of storms.
It could be possible that some EFIS formats or the crew’s unfamiliarity with them, contribute to reduced attentional resources, e.g. if strip speed formats require greater concentration than a dial presentation or the crew has recently changed to strip speeds, then the crew might not appreciate the change in workload. Similarly with any change FMA location.
It is often the small and seemingly innocuous changes in operating situations which lead to error.

Re:-

• Pilots are taught to fly on instruments; but are the techniques / skills used in manual flight the same as those when the autopilot is used; what changes, when, and why.
• Pilots should be able to recover from unusual attitudes; however, this assumes that the abnormality has been identified and correctly interpreted, particularly when suffering acceleration based disorientations. Disorientation is a significant hazard – it is difficult to identify and all crew can be affected simultaneously.
• Pilots should be capable of operating the aircraft systems correctly, but due to human limitations and weaknesses, we all make ‘small and irrelevant’ mistakes; except that the relevance depends on the context of the situation which also may have been misjudged and then these errors become potential contributors to accidents.

I would agree that the conjunction of a weak crew and an adverse situation was central to the accident, but the basis of safety in our industry depends on defenses in depth which mitigate the extremes of these hazards. Thus, the interesting issues might be why these safety nets apparently failed.

[mejjammm]

Food for Though..

· Why was the conversation btwn the captain and FO btwn Abidjan and Doula censored from the report?
·Why was the heated argument in the Yaunde Air Control tower btwn 2 air controllers on whether to clear the aircraft for take off or not under that stormy weather condition censored?
·The net tendancy of the A/C to roll to the right was not addressed fully in the report, was it a technical default ? was it a production malfunction?
·Prior to such incidences was it a requirement for the FO to verbally respond to the OK “COMMAND”?
·If the Captain initiated the engagement of the AP then why “ did it not engage”
·Did the AP disengage ? If so why was this not documented?
·Per earlier conversation the captain requested TWR that after takeoff they wanted to head right due to the weather condition ahead. Did the tendency of the A/C to bank right dissolution the crew into thinking that the AP was still engaged?
·Do 737-800 APs disengage under stormy conditions?
·Why didn’t the report mention pilot error as the cause of the accident but human factor?

[dvv]

mejjammm, the report clearly address the slight tendency of the aircraft to slowly roll when left to its own devices, see part 1.16.1. Airplane Performance; subpart B) Lateral Trim of the B737-800. Also, the report is convincing enough as to the reason for the AP's not engaging, see part 2.2.3.1, the third bullet point. Either way, please move the conspiracy theories to Jet Blast.

[jcjeant]

Hi,

mejjammm
You don't read enough PPRuNe forums .. otherwise you had understand
No conspiracies theories are admitted here.
No politics linked theories are permitted here.
In fact .. some wonder if rumours are permitted here.
Officials reports are here granted to be exact and true and can't be discuted.
So never write "coverup" or "Conspiracy"

[Re-Heat]

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.

Total CRM failure then. Have we not learned from the BEA Trident crash at Staines? What total lack of rigour allows these cockpit cultures to develop?

Age is irrelevant; cockpit culture is the failure here.

[keitaidenwa]

.: Capital FM Kenya: For Breaking News in Local, International, Business, Sports and Lifestyle :.
Airways-faults-2007-crash-report-8281.html

KQ agrees with report except for three minor details:

1. Auto pilot engagement

Unlike what the report says, the KQ insists that their SOP requires confirming autopilot engagement.

2. Safety Oversight Capacity

KQ complains that the report has conflicting opinions if KCAA if had or had not enough safety oversight.

(I agree with rcsa regarding with overbureacracy of KCAA, but that was not a contributing factor to this accident).

3. Crew Resource Management Training

KQ complains that the report has conflicting information if the first officer had went through CRM training.

Full statement from KQ :

http://www.capitalfm.co.ke/news/downfile.php?downId=48

IMHO Kenya Airways doesn't adequatly explain in the response how they have changed to ensure Douala and Abidjan accidents won't happen again. They emphisize that Kenya Airways has gone through IATA Operational Safety Audit (IOSA) and thus must be safe. But KQ was already through IOSA when Douala happened!!IOSA seems not much more than a paperwork excersize.

To the credit of KQ and the Kenyan media, they have not gone to the loony theories like flash airlines 604 or Egyptair 990.

[Frangible]

Why has there been so little comment on failure to request take off clearance?

Previous poster. If that's credit, then God help us all.

[PEI_3721]

What can we learn from this?

The operator has identified actions broadly in line with the report’s recommendations, but what else can the industry, operators, and individuals, learn from this accident. These points shouldn’t concentrate on curing the aspects specific to this accident, but should also consider related or generic issues which might lead to a similar accident in the future.

Several postings list alternative contributing factors, some have glib statements of cause, but few if any provide solutions to avoid this type of accident.
The recent accident record due to ‘loss of control / disorientation’ suggests that we haven’t learnt much over that last 4-5 years. Thus what can we learn now; what must we learn and how can safety be improved from these aspects?

I am reminded not to rush when engaging the autopilot, and after selection to check for correct engagement and the selected mode operation.
Before engagement confirm that the aircraft is in trim and no stick force is being held – like you, the autopilot does not like out of trim aircraft either.
These require self discipline, conscious thought and effort, all at the root of airmanship.
How can airmanship to be improved – a mixture of knowledge, habit, example, review, and memory, and with honest self criticism just to start with … but then we don’t always have good days.

Contributions?

[Whenwe]

I am deeply disturbed about the cause of this and other accidents. I remember the days when having a RMI was heavenly. A Flight Director ......wow!

We started digging this hole (sorry no pun intended) years ago.
If we are honest with ourselves, we need to ask if we can handfly the aircraft and comply with the accuracy that is required nowadays.

Otherwise; simply add the following to the 10000 ft checklist climbing and decending: Autopilot.... Engage / Disengage.

Take care out there.

[Capt Chambo]

Haven't had a chance to read the report yet.

This article appeared in "Flight" a few months ago. Combine it with recent threads about Airline Pilot's lack of manual flying practice and modern training programmes it makes for prophetic reading.

Pilot disorientation accidents have become a phenomenon

[mejjammm]

D.V.V.
Quoting the pargraphs you outlined

• 1.16.1 - Consequently ,It is established that at TO from Doula , the airplane has a tendency to roll to the right due to the combined effects of the inherent assemtry from construction and the slightly right position of the rudder trim.

To counter this roll tendency , some effort should be exerted to maintain the control wheel turned about 8 degrees to the left

• 2.2.3 -Bullet 2 -Then the captain calls "OK CMD" to engage the AP;he then behaves as though the AP is effectively engaged, something which is neither confirmed by announcement by FO,nor by the FMA , nor by the behaviour of the airplane itself.On the other hand , the automatic activation of the speed trim following excessive increase of speed could contribute to sustain his false impression of the AP being engaged.

• 2.2.3-Bullet 3 -There is no evidence why the AP didnt engage but the DFDR data incates a slight control column pressure as "OK Command" call is made by the captain.There is a possibilty that the selection was selection was made but the pressure on the column interfered with engagement of the autopilot. It should also be recalled that the AP"CMD A " had suffered recurrent breakdowns for a period of three moths prior to this flight.

This leaves us with more questions than answers-

Why are parts higlighted not included in section 3.2. probable causes -This in hand are major contributing factors in the accident -If they are addressed then such accidents can be avoided in future.
Can we speculate that there are other sources responsible for the accident ?

On Establised Facts items 34 & 35 are not deeply covered as the other items in the report , why? and their weigh in the cause of the accident is equivalent to the others

• 34- Information to crews was missing on the rolling tendency of the airplane during climb and descent and the elements that induce it including a) Rudder Thermal effect . b) Manufacturing asymmetry

• 35- Full information in the capability of the Autopilot CWS roll mode including ability to roll the airplane from bank angles of 50 degrees and above to 30 degrees bank is not explained in the Boeing Flight Manual

[Northbeach]

A few thoughts after reading the report.

Must admit I did not know about the thermal expansion of the rudder leading to the rudder deflection issue brought up in this report.

According to this report we are looking at a maximum .75 (3/4 of a degree) deflection left or right, or one and a half degrees total (1 ½) due to this phenomenon. No temperature data was given along with the ¾ of a degree off center figure. I have closed the report so don’t have the data in front of me. I don’t think the aircraft gained more than 3,000 feet AGL. Given the standard lapse rate we are talking less than 6 degrees temperature differential between the airport and the maximum altitude gained. So there cannot be much temperature change involved in this accident.

And, how long was it from rotation to impact? In this accident little time elapses from rotation to impact. Our temperature change is very small and our time frame is also very small. So, how much did the ruder deflect due to “thermal expansion” on this particular accident? Given my limited exposure to this “Rudder Thermal Expansion” phenomenon I would say precious little if any. Interesting academic exercise and information, but I doubt if it has any relevance to this accident.

This aircraft having an inherent tendency to roll to the right sounds menacing. The wording sounds like somebody is laying the ground work for a lawsuit against the manufacturer and/or airline for having a “killer airplane” loose on the public. Now if you take your hand off the beast and it rolls over on its back, we have an issue. If we are talking about a low, single digit 1-2-3 degree, roll to the left or right that would be a fairly routine occurrence. How many airplanes with the yaw and roll trim set at zero would stay perfectly in trim for any significant amount of time if you took your hand off the controls? In my world – none, and we fly over a hundred 737 airframes.

“Thermal expansion and deflection of the rudder” was an interesting technical point of this report. However I do not believe it has any bearing of this accident.

Mentioning the aircrafts tendency to roll to the right also has little to do with the cause of this accident.

I was impressed by the frankness and quality of the report. That reflects well on the issuing agency. I have no inside information, nor do I have any professional contact with any of the parties involved, I just fly the same model. Like many of you I have been waiting for the official report.

On a closing thought, it is sobering to have the comments recorded in one’s personal dossier made public. In this case the Captain’s shortcomings; CRM, systems, SA, performance and technical training failures highlighted several times.

[A37575]

* Pilots are taught to fly on instruments; but are the techniques / skills used in manual flight the same as those when the autopilot is used; what changes, when, and why.
* Pilots should be able to recover from unusual attitudes; however, this assumes that the abnormality has been identified and correctly interpreted, particularly when suffering acceleration based disorientations. Disorientation is a significant hazard – it is difficult to identify and all crew can be affected simultaneously.
* Pilots should be capable of operating the aircraft systems correctly, but due to human limitations and weaknesses, we all make ‘small and irrelevant’ mistakes; except that the relevance depends on the context of the situation which also may have been misjudged and then these errors become potential contributors to accidents.

Then why aren't Boeing 737's continually crashing all over the world if pilots are up against all those events you call up. You only have to be a simulator instructor to see such horrifying cock-ups by airline captains from various countries that you privately note NEVER to be a passenger with one of those operators. Why the head-long rush to engage the automatics immediately after take off? The Flash Air 737 crash was almost identical with the captain screaming for the autopilot to be engaged all the while the aircraft is spiralling in at 420 knots..

It is because airline pilots are getting more like trained monkeys, brain-washed by the manufacturers, the regulators and their airline ops management into avoiding hand flying like a plague. When you read the FCOM of one German 737 operator which that says "flying by hand is to be avoided unless under the most exceptional circumstances". You then know there is no hope for these idiots. This type of over-reliance on immediate engagement of the automatics is to be seen in most airlines now. This leads to laziness and complacency and finally total incompetence - with the inevitable final result we see in so many automation related crashes.

[Spadhampton]

NB....I agree!

It's almost as if they completely forgot how to fly.

Captain: “Are we crashing?”

Oh Please, these guys shouldn’t even have been allowed anywhere near that airplane!

[barit1]

Probably 5-10 years ago AW&ST had an article about the Canadian National Research Council with a Harvard configured with a "flexible" glass cockpit to evaluate various attitude displays. They invited guest pilots to test the displays in unusual attitude recovery - testing time to recognize the situation, and likelihood of applying the right corrective action.

Since my Dad once taught in AT-6's (Texan/Harvard) I'm sure he would have enjoyed the exercise. When students graduated, they were given the opportunity to put their instructors through a "hell ride" - and some of the students were better than their instructors!

See: http://www.nrc-cnrc.gc.ca/obj/iar-ir...arvard_eng.pdf

[soullimbo]

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.
Total CRM failure then. Have we not learned from the BEA Trident crash at Staines? What total lack of rigour allows these cockpit cultures to develop?
Age is irrelevant; cockpit culture is the failure here.

BEA Trident crash at Staines... What about the biggest disaster ever in Tenerife caused by an arrogant KLM captain? 30 odd years on and history repeats itself. The unfortunate thing is that this airline is part-owned by KLM.

[Oakape]

From another thread -

Article published in a UK magazine. Relevant to the subject of the opening post on the Kenya Airlines B737-800 crash.

George Has Control - or has he?

Once known as ‘George’ the autopilot has come a long way since the first one flew in 1912. But has an over-reliance on automatic systems degraded many pilots’ basic handling skills? .

. The Jeppesen ILS approach chart was for Noumea Runway 11, New Caledonia, ICAO designation NWWW. The MSA to the north-east is 7000 ft and to the south 5500 ft. An NDB, callsign NW, is on the extended centerline 8 miles from touchdown along with another NDB and VOR at the airfield. Following the recommended procedures published in the Boeing flight crew training manual, the crew made full use of the automatic pilot systems. As the aircraft turned to final approach a fault occurred with the No 1 engine thrust lever clutch motor. Thus, when the automatics commanded a thrust increase to maintain a set airspeed, the throttle lever of that engine would not move from the last setting prior to actuation of the fault. The last setting was throttles closed idle thrust. Manual throttle operation was not affected.



The autopilot was programmed to descend the aircraft to 1800 ft until intercepting the glide path. The captain called for the flaps to be extended to slow the aircraft to approach speed and the first officer set the correct speed for the flap setting into the autothrottle mode control panel. As drag from the landing gear and flap extension took effect the autothrottle system increased power to maintain the demanded airspeed but because of the autothrottle defect only one throttle moved to increase power.

With a large split between the throttles, the autopilot tried to compensate by using a combination of aileron and spoiler controls to maintain directional control. At this point both pilots were concentrating solely on monitoring the autopilot mode status, unaware of the asymmetric thrust and the steadily increasing control wheel angle. The landing check list was being read when the automatic pilot suddenly disconnected accompanied by the aural disconnect warning. Unconstrained by the autopilot, the aircraft rolled rapidly beyond 45 degrees, and losing height below the glide slope. By now the GPWS below glide-slope warning sounded and it was then for the first time the crew saw the marked difference between the throttle settings.

Observing the No 1 (left) throttle was against the idle stop and wrongly assuming the engine had flamed out, the captain called for the engine failure and shut down checklist. The first officer hurriedly reached down to locate the Quick Reference Handbook (QRH). Still scrabbling to find the right page, he never saw his attitude direction indicator (ADI) hard over beyond 60 degrees of bank and the altimeter winding down in a blur. In real life, a searching helicopter would have located wreckage at a position five miles from the airport and a quarter of a mile to the north of the ILS inbound track. There would have been no survivors. At the time of estimated impact the simulator made a loud graunching noise and the windscreen turned red with simulated blood (a macabre modification by the technicians to the windscreen view to signify Heaven’s open door. So great was the impact, a re-boot of the simulator was necessary.
Modern airliners are equipped with superbly reliable automatic flight control and navigation systems. And certainly the remarkable reduction in CFIT over the years, attest to this. Yet there is a downside. One sage pilot described this perfectly when he said that automation robs situational awareness through absence of physical/sensory cues of flying the machine and as a result atrophies flying and thinking skills. He added that when automation degrades it can overwhelm even a highly competent well-trained crew. Other than that, automation used as intended - and not as an aircraft babysitter - was a tool for accuracy, predictability and timeliness of action.

Automatic throttle control systems have featured in several fatal crashes. In 1992, a China Airlines Boeing 737-300 crashed 15 miles from its destination. During the visual approach, with the autopilot and autothrottle engaged, the left thrust lever advanced while the right one remained at the idle position. The crew apparently failed to notice this asymmetrical power condition and allowed the aircraft to roll into a spiral dive.

Three years later in 1995, an Airbus A310 crashed in a steep nose-down attitude three minutes after take off. According to the accident report, the crash apparently resulted from a malfunction in the aircraft’s autothrottle system when power was reduced from takeoff to climb thrust. Mechanical jamming of the right throttle resulted in this engine remaining at full-power setting, causing an asymmetrical thrust condition that led to loss of control. The crew was slow to recognize the malfunction, which occurred over a period of about 40 seconds beginning when the aircraft had reached 2000 ft and continuing after it was cleared by ATC for a left turn. During this turn, the left bank steepened, with the Airbus over-banking into an 80 degree spiral dive and 290 knots before impact. Recommendations issued by the French Director General of Aviation in the wake of this accident, included the careful monitoring of throttle behaviour when the autothrottle is engaged, and its immediate disconnection and reversion to manual control if a malfunction occurs. Of course that was only saying the bleeding obvious, but crashes due to crew mishandling still occur.

In 1998 another Airbus crashed. This time at Taiwan, during a go-around from a high approach. Instead of disconnecting the autopilot when it was apparent that it was not coping quickly enough with thrust changes, the crew persisted with autopilot operation only to stall the aircraft due to an excessive out of trim situation, killing all aboard. Four years earlier an almost identical crash had occurred at Nagoya, Japan where investigators determined an extreme out of trim condition caused the aircraft to pitch up uncontrollably until it stalled.

In 1985, a China Air Boeing 747 flying at 41,000 feet over the Pacific in cloud and in moderate turbulence, experienced an autothrottle defect that caused one throttle to stay at idle thrust. Initially, there was no action taken to turn off the autothrottle system and adjust the power manually. In spite of having several minutes to act, the pilot failed to control the yawing moment and the 747 rolled inverted into a spiral dive. It reached Mach 1.0 and 5g, losing 30,000 feet before recovery was made below cloud at 9000 feet. .

Fast forward to 2009 where a Flight International headline reported Thomsonfly stall pinned on autothrottle.. No one was hurt when in September 2007 the Boeing 737-300 came close to stalling during a night ILS approach to Bournemouth airport, UK. The autopilot and autothrottle had been engaged at the start of the approach. However, an undetected malfunction caused both thrust levers to stay closed instead of holding approach power with flaps down. The crew did not notice the subsequent loss in airspeed as the autopilot tried to hold the ILS glide slope. The captain conducted a belated go-around with the aircraft reaching a pitch attitude of 33 degrees and speed of 82 knots before he was able to get the situation under control.

Not so fortunate, was Turkish Airlines Boeing 737-800 Flight 1951 that crashed in February 2009 during an ILS approach to Amsterdam. A defective radio altimeter fed wrong information to the autothrottle system causing the throttles to close to idle thrust. Like the Bournemouth incident, the autopilot tried to maintain the ILS glide slope by pitching up and trimming back. For over a minute the crew noticed the throttles were closed yet apparently failed to take corrective action until too late to prevent the aircraft stalling into a field, killing several passengers and crew members.

In most of the cases mentioned, prompt action by the crew to notice the worsening situation followed by immediate action to disconnect the automatic pilot system and fly the aircraft manually, may well have prevented each accident. As one pilot warned “Do you control the automated cockpit or does it dominate you?” While aircraft manufacturers encourage full use of automation, it is surely with the unspoken caveat that if automation is distracting your flight operation, early intervention should prevent things from getting out of hand. The Boeing 737 flight crew training manual covers this by recommending reduction of the level of automation as far as manual flight, to ensure proper control of the aircraft is maintained.

That last paragraph,” reducing the level of automation as far as manual flight” reveals the importance placed by manufacturers - and indeed airline operators, on the flight safety value of auto flight systems. Yet, the countervailing argument that manual flight skills are just as essential as automation is rarely mentioned in official manuals.

Perhaps a similar misguided philosophy led to the death of all 112 on board when an Adam Air Boeing 737-400 crashed into the Makassas Straits off Selawisi Island, Indonesia. The accident summary said the cause of the accident was failure of the pilots to monitor their flight instruments while trouble-shooting the navigation system. While in cloud, the automatic pilot disconnected as the crew were engaged in discussion of an apparent defect in the inertial navigation system. Unnoticed by either pilot, the 737 gradually entered a steep spiral dive. When the penny dropped, and the captain realized his aircraft was rapidly getting out of control, he made matters worse by pulling back hard on the control column instead of using the correct procedure for recovery from an unusual attitude. The aircraft broke up in the air.

We need a happy ending for a change, so you are invited to contrast the actions of the ill-fated Adam Air crew with those of a Mystere 20 Falcon crew faced with an unexpected runaway stabilizer electric trim on short final to runway 16 at Sydney, NSW, Australia. This is an edited extract from the Bureau of Air Safety Investigation of the incident. Keep in mind, the aircraft was flying over built up areas immediately surrounding the airport because this report will make your hair stand on end. The captain had 14,100 flying hours experience while the copilot had 8000 hours.

Following a normal flight the aircraft was established on final approach for landing. At about 140 feet above the ground, the approach angle flattened and the nose pitched up. The co-pilot, who was flying the aircraft, believed that a wind-shear situation had been encountered, and he initiated a go-around. As full power was applied the nose pitched up violently. The crew did not observe any cockpit indications as to the reason for this reaction.

The pilot in command took control of the aircraft and initiated a rolling turn. This had the effect of reducing the pitch angle, and by manipulating power levers and rolling, the pilot was able to regain control of the aircraft at about 6500 feet. A safe landing was subsequently carried out. Witnesses later reported that they observed the aircraft had reached pitch and bank angles of 60 and 40 degrees respectively. Because there had been no indication of the cause of the initial pitch up, the crew had difficulty in determining the appropriate course of action. Although the investigation revealed the initiating factor was probably a full nose-up trim situation, the crew believed the problem was caused by a structural failure or a thrust reverser malfunction

This brief official description of the incident did not tell the full story, however. In his report, the pilot stated (edited for brevity): At 140 feet above runway 16 the copilot stated that things were wrong and he was going around. Power was applied and loss of pitch control followed immediately. I took over control of the aircraft and I can still recall the IAS drop below 107 knots. I had both hands holding the control column fully forward trying to limit the rearing of the body angle. My concern was that we were going over on our back which would have been the end, as this manoeuvre started at about 80-90 feet AGL. In my mind was that the vertical lift of the aircraft had to be minimized so I rolled it to the left in a very steep turn and had the copilot close the throttles to assist me in getting the nose of the aircraft to come below the horizon. This turned out to be successful and we recovered prior to ground contact. As power was restored the nose pitch attitude reached again the 60 to 80 degrees (as some witnesses in the control tower claimed)

During the first go-around the flaps and gear were retracted and we did a series of the above manoeuvres, using roll and power off and an application technique as described above, each time gaining some height above ground level although we had very limited heading control. We did this for about 5 or 6 times and obtained about 6500 feet AMSL During this time I was unable to take either hand off the control column or relax the force required to limit the rear of the body angle. The copilot was completely occupied with the closing and opening of the throttles to help me semi-control the nose position. The aircraft eventually flew out of the problem and returned to normal operation with no further input from the crew.

Once the first recovery had been achieved I knew that I could control the aircraft to a certain extent whilst the fuel lasted. This could not have been possible without the excellent crew co-ordination between PF and PNF. A help to me was the knowledge of aerodynamics instilled by instructors during my early training on Tiger Moths.

During the technical investigation of the incident no fault could be found in the stabilizer actuator although another fault which was considered responsible may have been intermittent in nature. The captain of the Mystere Falcon exhibited superb airmanship in recovering the aircraft from a deadly situation and if a military pilot would no doubt have been recommended for the award of the Air Force Cross. This was pure flying skill at its best.

But all that happened many years ago. The game has changed since then, and now we have the situation almost world-wide where low cost airlines recruit low experience pilots as second in command of large airliners. While this may be partly due to a perceived shortage of experienced pilots, it is more likely aimed at cost-cutting where pilots are willing to pay for their own training on passenger jets. It is common to see newly graduated commercial pilots self funding a type rating on a Boeing or Airbus. Next thing is to find an airline happy to offer them a first officer position. No problem there, with agencies keen to place them (at a price, of course) with an airline willing to hire them in the right hand seat for six months. Captains are expected to look after the new boy or girl by giving them take off’s and landings in fair weather as the youngsters build up their jet hours to qualify for full-time jobs.

Because of the low experience of many new first officers, it is with some relief their mentors can plug in the automatics from take off to landing and sit back and relax while the first officer merely monitors the automatic pilot on his leg. With airline policy dictating the full use of automatics during revenue flying the exposure to the real world of manual flying for skill retention, is neatly side-stepped.

In this article we have read of fatal accidents caused by crew mis-handling the automatic systems – particularly while flying at night or in IMC. Statistics reveal Loss of Control as the new major cause of aircraft fatal accidents. This was highlighted during a recent Asia Pacific Airline Training Symposium held in Hong Kong where the Airbus representative urged the aviation industry to confront the issue of how to ensure long-haul pilots maintain basic flying skills in the face of ever-increasing aircraft reliability and cockpit automation. “I think that at a certain point in time we need to bring back a little bit of handling”. He advocated more simulator time for pilots to hone their basic skills. “We put people into our training today who have forgotten how to fly, basically” That would surely be the understatement of the year.
Of course not all pilots have forgotten how to fly. But consider this true story of a 2000 hour newly recruited first officer at the controls (on automatics, of course!) of a Boeing 737. With the airport in sight at 15 miles, the captain suggested it would be a good opportunity for his Number One to disconnect the automatics and fly by hand. This perfectly reasonable suggestion was met with a shocked look and shaking of the tousled head as the first officer said no way was she going to hand-fly when the automatics did a better job – passenger comfort and all that jazz. Now it was the captain’s turn for the shocked look and shaking of head. Another time, a keen first officer asked his captain if he (the first officer) could turn off his flight director during a VMC climb so he could practice raw data manual flying. The captain refused; saying, leave that to the simulator.

While some of the more enlightened operators permit manual flying in appropriate airspace and weather conditions, others discourage it. A regional operator in Australia flying turbo-prop commuter aircraft insists crews use full automation from after lift-off to short final even in CAVOK conditions, leading to the ridiculous situation where furious knob twiddling of the autopilot takes place as the aircraft tracks from downwind to base and final in the circuit area. These are the same crews that eventually move up the food chain to fly the big jets. The regulator doesn’t mind one bit as long as rules are not broken. .

The reality is that manufacturers and airline operators will not venture from their comfort zone and encourage pilots to hand fly at their discretion. Some captains will quietly encourage a spot of manual flying here and there – flight directors on, of course. No point in stretching the friendship too far, they say. One captain interviewed observed that automation complacency is so well entrenched that many pilots politely decline his suggestion they hand fly on raw data occasionally –even if a recurrent simulator session is getting close. A few months ago, a Boeing Company check pilot talked to pilots of a major Hong Kong-based airline. In his travels, he noted that some airline pilots tended to avoid the opportunity to practice hand flying skills until the very last minute before a simulator session. This was a waste of time, he said – because manual flying skills had to be maintained throughout the year and that a hand flown ILS in good weather after months on autopilots, did nothing for basic flying skills.

Following the UK report on the near stall of the Thomsonfly Boeing 737-300 mentioned earlier, Flight International quoted a CAA observation that: Pilots familiar with operating older aircraft, which had more variable reliability, are nearing the end of their careers, and there is a generation of pilots whose only experience is of operating aircraft with highly reliable automated systems.” The writer maintained that exercises mandated in recurrent training programmes have scarcely changed since the days of the Super Constellation. So training no longer represents what crews are likely to have to deal with today.

The solution is change the mind-set of regulators and operations departments. While Loss of Control accidents will never be eradicated, training departments should learn the lessons of past accidents and apply them to more realistic simulator training. Normally in recurrent simulator training, each crew member can expect two hours per session as pilot flying. Over a 12 month period this amounts to at least eight hours of handling per year depending on the number of sessions scheduled. Most of these sessions in the simulator will be on automatic pilot, with occasional manual flying to meet regulatory requirements. One engine inoperative flying forms a good proportion of each simulator session and much of that is on automatic pilot. This does not leave much time for practicing raw data pure flying skills. That policy must change if airlines are serious about learning the hard earned lessons from past accidents.

While LOFT exercises are valuable for practicing CRM skills, they rarely provide manual handling practice. Valuable simulator time is sometimes wasted in lengthy LOFT scenarios that require complex checklist use and associated crew discussion. Often the pilot finds he has done only two landings by the end of the session. To ensure a high standard of manual flying skills are maintained throughout the year (not an unreasonable expectation), simulator sessions should be scheduled to allow equal time between automatics and raw data manual flying. If that is a problem then additional time should be scheduled. Simulator training might be expensive but peanuts compared to the cost of a crash such as those described above.

Pilots should be given the opportunity to practice raw data hand flying in sequences covering high and very low altitude stall recovery, circuits and landings in strong crosswinds, unusual attitude recoveries, GPWS pull up manoeuvres, bad weather low level circuits, forced landings following loss of both engines, flight on standby flight instruments, instrument approaches general and all flaps up landings on limiting length runways. Additional sequences could include black-hole approaches over terrain devoid of ground lighting, and slippery runway short field landings. For the purpose of all these exercises, the automatic pilot, autothrottle and flight directors should be left off. To keep these pure flying sessions within reasonable time limits, the instructor should use the freeze and re-positioning facility of the simulator as well as common-sense reduction of QRH and checklist reading. Keep in mind the aim is to allow the pilot the opportunity to practice basic handling skills within the time constraints of simulator scheduling.

Earlier, mention was made of the superb skill and airmanship displayed by the captain of the Mystere 20 Falcon at Sydney, in recovering from a series of extreme attitudes caused by a stabilizer trim malfunction. He attributed this skill to lessons instilled into him by his instructors on Tiger Moths. Who knows that one day in the future, a pilot recovering from a one in a million jet upset in a highly automated airliner will thank his simulator instructor for teaching him the art of pure flying.

[etherate]

This was certainly a fascinating report. I too, like some other posters, had also never heard of the rudder thermal expansion issue, despite having been on 73s for some 15 years. One immediately wonders if there will be parallels with the Ethiopian 737 crash out of Beirut. Certainly has all the hallmarks (without of course jumping to any conclusions or cast any aspersions about the crew of that aircraft).

I agree that the takeoff without clearance was symptomatic of a lot of what was going wrong in that flight deck from even before taxy. Lack of proper crew coordination, fixation on expected poor weather to the exclusion of everything else.

What I thought was particularly interesting and may well send ructions through the industry, was the emphasis on crew training and performance records. Hidden in there somewhere was a gem about [crew] "pairing". Just wait til the lawyers get hold of that !
It is in a similar vein to the Helios report where two (shall we say, say fairly weak) individuals were "paired" together, and when the right circumstances all came together a disaster ensued. It does not make good reading for KQ.

Is it going to put pressure on airlines to be a lot more hard-nosed about persistent under-performance? All credit to KQ for having the sufficiently well documented training records for the investigators to find all this information. I can think of some companies where the training records may not have been so forthcoming.

This accident really does put loss of manual handling skills right back up there at the top of the debate.

[misd-agin]

1. 737 has tendency to roll to the right. It's similar to the amount of roll you'll find in any a/c on takeoff(which could be left or right) except that it's almost always to the right on the 737.

2. A/P engagement is very sensitive in the 737-800. Almost any control column pressure will prevent A/P engagement. Nothing new there for anyone that flies the a/c.

[Spadhampton]

Nothing wrong with this airplane...

There was nothing wrong with this aircraft. NOTHING!

Except incompetent pilots. Very plain, very simple.