TAM A320 crash at Congonhas, Brazil
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Originally Posted by SoaringTheSkies
Or in other words: human error is intolerable.
Pilots are highly-trained professionals so that they do not do it by accident. That they still do it is human nature.
On the other hand there are certainly many occasions on which human interaction saved the aircraft in a critical situation. We only notice those very few occasions, where they didn't succeed. Only accidents make the news.
But retarding thrust levers to idle in the flare is among the most basic airmanship skills, and it is impossible to protect against basic flying mistakes, unless you go all the way to 100% automation and elimination of the pilot. We are not there yet.
Still, I am not seeking to apportion blame, the question must be asked "why did they not do the sensible thing they were trained to do, and did on all previous approaches?"
To find that out will be the task for the experts.
To decide whether the found reason merits the mandatory installation of the warning system alerting the pilots to their mistake is to decide for the authorities.
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I've been flying the Airbus for nine years now and flown with a few T/R's inop, I wonder how many successful landings have been made throughout the years with T/R's inop?
I's sure a great system as long as everything performs in accordance to what has been envisioned in the design phase, but humans are very creative in their ways to err.
pj
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Bomarcs last ditch procedure would have worked better than what was done but what happens to the antiskid system when you lose all of your AC busses? Boeing systems don't put you in that predicament. Boeing systems are so much more pilot user friendly than Airbus. You always get what you ask for. You don't have to see if Airbus logic agrees. When have you seen a Boeing aircraft go off the end of a runway over 100 knots because the pilots could not control the thrust? No matter who is at fault.
On the Airbus the antiskid is controlled by the BSCU (Brake/Steering Control Unit) which is DC powered, not AC. The BSCU has two channels, one powered by a main DC bus and the other by a DC essential bus. In the case of the A330 (and I suspect the A320 as well) the BSCU channel will remain powered even in the emergency electrical configuration (for the A330, Land Recovery on and a/c not on batteries only) allowing the antiskid to work.
So, how is this any different or less "user friendly" than a Boeing? For that matter how can you classify operation of the antiskid, which is almost entirely autonomous on both manufacturer's aircraft as having any "user friendliness" quotient at all?
When have you seen a Boeing aircraft go off the end of a runway over 100 knots because the pilots could not control the thrust? No matter who is at fault.
BTW, I'm just curious about how many hours of operating experience on Airbus A320/A330/A340 aircraft lie behind your assertion that "Boeing systems are so much more pilot user friendly than Airbus." I'd assume you have at least a thousand hours or more on both manufacturer's models before you'd be so bold as to venture that sort of an opinion?
ELAC
Or in other words: human error is intolerable.
To be human is to err. However, some systems are designed with human nature in mind, so the consequences are nil.
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quote barit:
...and at this point in what we know of the investigation, the only surprise to me (forgive the gallows humor) is that the CVR didn't capture the words "What's it doing now???"
but that is just what I believe is ment by the 'olha isso' or 'look at this'....
...and at this point in what we know of the investigation, the only surprise to me (forgive the gallows humor) is that the CVR didn't capture the words "What's it doing now???"
but that is just what I believe is ment by the 'olha isso' or 'look at this'....
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hmmm
by the Airbus telex and what seems to be consensus among those ppl defending the AB system, can I assume that the outcome might be similar to:
Cause of accident: PF failed to retard the #2 thrust lever.
The aircraft performed as designed.
Or in other words: human error is intolerable.
Sorry if this is not very positive posting, but I can't help thinking that's the way it's heading.
I still can't help my personal feeling that, even though the aircraft did perform as designed, it was the design that turned this human error into a disaster.
pj
by the Airbus telex and what seems to be consensus among those ppl defending the AB system, can I assume that the outcome might be similar to:
Cause of accident: PF failed to retard the #2 thrust lever.
The aircraft performed as designed.
Or in other words: human error is intolerable.
Sorry if this is not very positive posting, but I can't help thinking that's the way it's heading.
I still can't help my personal feeling that, even though the aircraft did perform as designed, it was the design that turned this human error into a disaster.
pj
Please! And you want to talk about other posts being polemical?
To follow your logic would be to imply that every accident resulting from a gross human performance failure should simply be laid at the feet of the manufacturer for not having designed a system that was sufficiently "Human Error Tolerant". That's not a credible position to take for most such accidents, be they to a Boeing, an Airbus or to any other type of aircraft.
The manufacturer is entitled to some baseline assumptions regarding properly trained pilot behavior and reactions. I'd suggest that retarding all thrust levers upon landing is quite reasonably one of them. If those baseline assumptions cannot be met by the crew operating the aircraft then it becomes virtually impossible for a manufacturer to produce a design that will cater for every possible variation in the crew's response.
ELAC
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siding with SoaringTheSkies
I only fly a desk, but I tend to agree that Airbus will seek to escape all blame in this instance. Yes the plane performed as designed. Yes it did. But along with others on this thread who expressed the same sentiment. Something is terribly wrong with the "logic" that this accident was somehow acceptable. Just because its deemed to be nearly impossible to occur. Because most AB pilots are comfortable and competent with A320 control logic. Add to that any number of other valid reasoning. However, why should a relatively innocous human mistake be allowed to progress to such a terrible end. A well designed ship's hull can mitigate the movement of the waves and keep the ship steady, while one that is badly designed accentuates wave movement and could easily flounder. I say that Airbus' logic floundered in this situ. However rare, this type of incident has happened several times. If sensors on the wheels detected the plane was on the ground and one reverse was in operation (which is commonly understood by pilots to mean a full stop is the only option) then the aircraft should assume a FULL STOP is required and allow all its available systems to aid in just such an endeavor. In such an instance spoilers should activate and brakes should be set to max the moment pedal pressure is applied (or better yet full Auto Brake is initiated) . No one has yet come up with a likely scenario where a pilot would want half the plane to stop and half of it to take off. Even if only one reverse is activated and the plane is on the ground should mean a FULL STOP is the only sensible and plausible intention.
This accident should not have happened. This A320 was mishandled yes, but the plane,s logic needs to be revised to accomodate, if you will, the human element. So that relatively minor mistakes can be mitigated instead of augmented. Airbus is proud of its envelope protection against pilot departures from SOP. Well , this certainly is a departure from SOP. But the plane could well be revised to take the appropriate actions to save itself in just such a scenario if/when it happens again.
Airbus is NOT blameless in this accident IMHO. The control logic behind the A320 needs urgent and careful revision.
This accident should not have happened. This A320 was mishandled yes, but the plane,s logic needs to be revised to accomodate, if you will, the human element. So that relatively minor mistakes can be mitigated instead of augmented. Airbus is proud of its envelope protection against pilot departures from SOP. Well , this certainly is a departure from SOP. But the plane could well be revised to take the appropriate actions to save itself in just such a scenario if/when it happens again.
Airbus is NOT blameless in this accident IMHO. The control logic behind the A320 needs urgent and careful revision.
The Reverend
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Did you look at my post about the Air France B747-400 that finished up in the lagoon at Papeete? I thought the message was fairly obvious. Doesn't matter if it's Airbus or Boeing, they are all aeroplanes and if you mishandle them, they will bite you!
Armchairpilot,
With all due respect, you are only familiar with flying your armchair.
If you take away the basic actions of the basic flying controls, you are asking for trouble. To have a thrust setting dropped "for you" by a logic system opens a can of worms if you either have a faulty logic system, or if the pilot wants the thrust but the logic says no.
Far easier to incorporate yet another system warning "ding" to quickly bring your attention to the possibly unusual or erroneous configuration - and I believe this is exactly what Airbus are doing with the latest software (H2F3?).
With all due respect, you are only familiar with flying your armchair.
If you take away the basic actions of the basic flying controls, you are asking for trouble. To have a thrust setting dropped "for you" by a logic system opens a can of worms if you either have a faulty logic system, or if the pilot wants the thrust but the logic says no.
Far easier to incorporate yet another system warning "ding" to quickly bring your attention to the possibly unusual or erroneous configuration - and I believe this is exactly what Airbus are doing with the latest software (H2F3?).
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I recounted a story in my only previous post in this thread about how a few mm made all the difference.
In this case, it appears 7.5 degrees of No 2 thrust lever movement would have been enough to avoid this accident (amongst other things).
How many times have the pilots on this thread incorrectly set an altimeter setting, only to have it picked up by their colleague, incorrectly entered a de-rate, only to have it picked up by their colleague.....
Small numbers have big impacts in this profession.
Whilst the report on this accident will, no doubt, run to hundreds of pages, simple errors of omission or commission can spoil your day.
To the Boeing luddites amongst us (I'm a Boeing pilot), there was nothing (technical malfunction notwithstanding) stopping the pilots retarding the second thrust lever was there?
And I certainly agree with the analysis already advanced that suggests when the system encounters an ambiguous intention/demand, then, the logic should give an output that correlates exactly with the system state vector, incongruous as that might be.
To me, that is evidence of a very clever system indeed, and on the day, it is starting to look like everything was working as intended.
Does Occam's Razor apply in aircraft investigation?
In this case, it appears 7.5 degrees of No 2 thrust lever movement would have been enough to avoid this accident (amongst other things).
How many times have the pilots on this thread incorrectly set an altimeter setting, only to have it picked up by their colleague, incorrectly entered a de-rate, only to have it picked up by their colleague.....
Small numbers have big impacts in this profession.
Whilst the report on this accident will, no doubt, run to hundreds of pages, simple errors of omission or commission can spoil your day.
To the Boeing luddites amongst us (I'm a Boeing pilot), there was nothing (technical malfunction notwithstanding) stopping the pilots retarding the second thrust lever was there?
And I certainly agree with the analysis already advanced that suggests when the system encounters an ambiguous intention/demand, then, the logic should give an output that correlates exactly with the system state vector, incongruous as that might be.
To me, that is evidence of a very clever system indeed, and on the day, it is starting to look like everything was working as intended.
Does Occam's Razor apply in aircraft investigation?
Can somebody explain to me (especially the very experienced armchair pilots 
), the difference between the A320 & 737NG in this scenario.
The 737 would have ended up in exactly the same position, possibly even crossing the road faster as the reverser would not have unlocked.
), the difference between the A320 & 737NG in this scenario. The 737 would have ended up in exactly the same position, possibly even crossing the road faster as the reverser would not have unlocked.
The tragic aspect of this accident is that the fixes should already have been in place. Does anyone think this accident would have happened if a) the Taipei SB had been incorporated (I assume it is on new build aircraft) and b) the new MEL procedures for inop TR (ie use TL as normal) had been effectively promulgated by the airline & followed by the crew ?
What more is needed?
What more is needed?
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Thats just arrant nonsense.
Who is saying it's acceptable?
There are no certainties in aviation design, only probabilities, and all manufactureres work to the same probabilities.
As has been said many times before, if you make enough mistakes you can wreck any system, whether it's an Airbus, a Boeing or even a ship. It doesn't matter how well you design a ship, if you enter port with one engine in reverse and the other full steam ahead the results will not be pretty.
Yes they did, a few pages back. Engine 1 stuck in reverse and a go-around required.
I thin we all agree on that.
Indeed it was
But which human element to accomodate? If you interpret in one way then you can bet your bottom dollar someone will attempt to operate it the other way and come a cropper. A baseline error like not closing the thrust levers is not the kind of thing you should have to design against. It's as obvious as saying don't fly the thing upside down into a mountain. Remember these machines are designed to be flown by highly trained professionals, not monkeys.
The envelope protection protects against departure from controlled flight and extreme manouvres, not against departure from SOP. That is a very different thing.
It is a departure from SOP, but not necessarily something Airbus should design against.
Something is terribly wrong with the "logic" that this accident was somehow acceptable.
Just because its deemed to be nearly impossible to occur.
However, why should a relatively innocous human mistake be allowed to progress to such a terrible end.
No one has yet come up with a likely scenario where a pilot would want half the plane to stop and half of it to take off.
This accident should not have happened.
This A320 was mishandled yes
but the plane,s logic needs to be revised to accomodate, if you will, the human element. So that relatively minor mistakes can be mitigated instead of augmented.
Airbus is proud of its envelope protection against pilot departures from SOP.
this certainly is a departure from SOP. But the plane could well be revised to take the appropriate actions to save itself in just such a scenario if/when it happens again.
Last edited by Hand Solo; 6th Aug 2007 at 11:17.
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ELAC,
yes, I was polemic with this post.
To err is human, it's a fact that we both seem to agree on.
Most human-human communication has enough redundancy to allow for errors.
If I, as an engineer, am building a system which communicates with a human, I need to obey three rules that I have outlined twice before:
1. avoid error as far as possible (by human centric interface design)
2. tolerate error where possible (make sure there's enough communication redundancy so that a single human error cannot render the whole system clueless)
3. fail gracefully if #1 and #2 did not work
I do not want to fingerpoint every human error to the manufacturers, or, more generally speaking, to the designers of a certain system.
But I do want to point out that the AB system has imho failed on all three levels.
1. avoid error: due to the fact that the thrust levers are stationary, there's a chance that the PF does not move them, however outlandish and improbable that may be, it has happened here and it has happened before.
2. tolerate error: the "thrust levers in or near idle" clause is a hard inhibitor to ground spoilers deployment and thus indirectly to autobrake. A second clue to the system could be beneficial here (this has been called a "red button" or "override function" in this thread, but technically more reasonable would be, for example, to use manual brakes as an override clue for the gs logic)
3. fail gracefully: this is a difficult bit. #1 and #2 try to catch things that you can envision. #3 has to deal with things you have not thought of and do so without jeopardizing other scenarios - thought of or not.
I won't make a guess what that would be, but I think we can agree that the system has failed far from gracefully in this case.
So please excuse my polemics, but I just can't take the implied "bad airmanship" as the sole answer to this, especially not in the light that it's not the first time this same "bad airmanship" error has occurred.
I hope that anyone who posts here finds himself in a forgiving environment when he makes the next mistake.
pj
yes, I was polemic with this post.
To err is human, it's a fact that we both seem to agree on.
Most human-human communication has enough redundancy to allow for errors.
If I, as an engineer, am building a system which communicates with a human, I need to obey three rules that I have outlined twice before:
1. avoid error as far as possible (by human centric interface design)
2. tolerate error where possible (make sure there's enough communication redundancy so that a single human error cannot render the whole system clueless)
3. fail gracefully if #1 and #2 did not work
I do not want to fingerpoint every human error to the manufacturers, or, more generally speaking, to the designers of a certain system.
But I do want to point out that the AB system has imho failed on all three levels.
1. avoid error: due to the fact that the thrust levers are stationary, there's a chance that the PF does not move them, however outlandish and improbable that may be, it has happened here and it has happened before.
2. tolerate error: the "thrust levers in or near idle" clause is a hard inhibitor to ground spoilers deployment and thus indirectly to autobrake. A second clue to the system could be beneficial here (this has been called a "red button" or "override function" in this thread, but technically more reasonable would be, for example, to use manual brakes as an override clue for the gs logic)
3. fail gracefully: this is a difficult bit. #1 and #2 try to catch things that you can envision. #3 has to deal with things you have not thought of and do so without jeopardizing other scenarios - thought of or not.
I won't make a guess what that would be, but I think we can agree that the system has failed far from gracefully in this case.
So please excuse my polemics, but I just can't take the implied "bad airmanship" as the sole answer to this, especially not in the light that it's not the first time this same "bad airmanship" error has occurred.
I hope that anyone who posts here finds himself in a forgiving environment when he makes the next mistake.
pj
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armchairpilot,
I think you mis-understand the other perspective being put forward here. I don't see anybody saying that this or any accident is acceptable. It is not, and every effort towards finding the causes and solutions should be made. No arguement there at all.
Where we part ways is in describing a failure to retard TL2 (should that be determined to be the initiating factor) as a minor or "relatively innocous human mistake" in piloting. It is not. It is a very major breakdown in basic airmanship. To use your nautical analogy, this situation is roughly the equivalent of turning the tiller the wrong way or applying power in the wrong direction while attempting to maneuver a ship into a tight slip with a strong current behind you. If you do this and do not make an immediate and forceful correction you are going to hit the dock hard every time. Depending on how hard you hit you may just bruise your ego, or you may end up going down with the ship.
If this is what happened, the question of why it happened, along with why no other braking actions were taken for 11 seconds after landing, will be the critical questions for investigation in my view. Those answers could lie in procedural guidance or emphasis relating to the reverser inop condition, they could lie in what training was provided for the situation, or they could lie with something particular to the individual handling the aircraft. Hopefully careful investigation will determine that.
As to the airplane's system design, that too should be fully investigated, but there is nothing so far in the public realm that suggests that the airplane did anything other than what it was commanded to do, or that the aircraft response to those commands would have been appreciably different in most other currently certificated designs. If the investigation finds something not immediately apparent in the design that did contribute adversely to the outcome, then by all means lets fix it. But before we jump, let's make sure that we are fixing it with something that enhances the overall safety of the aircraft as opposed to introducing a behavior that would have been helpful in this specific set of circumstances but would be unhelpful or have a negative impact in a greater number of other more probable failure conditions.
From what we know so far, the most pressing question with regard to the aircraft seems to be: Why was the available mod regarding the ECAM warning "ENG X THR LEVER ABOVE IDLE" with CRC not mandatory and why was a decision made not to install it at TAM even though it was available? That's a question that I think Airbus, the regulators and TAM will all be squirming about, and probably they should be.
ELAC
I think you mis-understand the other perspective being put forward here. I don't see anybody saying that this or any accident is acceptable. It is not, and every effort towards finding the causes and solutions should be made. No arguement there at all.
Where we part ways is in describing a failure to retard TL2 (should that be determined to be the initiating factor) as a minor or "relatively innocous human mistake" in piloting. It is not. It is a very major breakdown in basic airmanship. To use your nautical analogy, this situation is roughly the equivalent of turning the tiller the wrong way or applying power in the wrong direction while attempting to maneuver a ship into a tight slip with a strong current behind you. If you do this and do not make an immediate and forceful correction you are going to hit the dock hard every time. Depending on how hard you hit you may just bruise your ego, or you may end up going down with the ship.
If this is what happened, the question of why it happened, along with why no other braking actions were taken for 11 seconds after landing, will be the critical questions for investigation in my view. Those answers could lie in procedural guidance or emphasis relating to the reverser inop condition, they could lie in what training was provided for the situation, or they could lie with something particular to the individual handling the aircraft. Hopefully careful investigation will determine that.
As to the airplane's system design, that too should be fully investigated, but there is nothing so far in the public realm that suggests that the airplane did anything other than what it was commanded to do, or that the aircraft response to those commands would have been appreciably different in most other currently certificated designs. If the investigation finds something not immediately apparent in the design that did contribute adversely to the outcome, then by all means lets fix it. But before we jump, let's make sure that we are fixing it with something that enhances the overall safety of the aircraft as opposed to introducing a behavior that would have been helpful in this specific set of circumstances but would be unhelpful or have a negative impact in a greater number of other more probable failure conditions.
From what we know so far, the most pressing question with regard to the aircraft seems to be: Why was the available mod regarding the ECAM warning "ENG X THR LEVER ABOVE IDLE" with CRC not mandatory and why was a decision made not to install it at TAM even though it was available? That's a question that I think Airbus, the regulators and TAM will all be squirming about, and probably they should be.
ELAC
Last edited by ELAC; 6th Aug 2007 at 10:44.
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100pct Please
Yes you guys are the pros and thus I wanted to ask you if any pilot so far has dis-agreed that once reversers are deployed you should come to a full stop?
Did the A320's electronic brain (if you will) fail to recognize that reverser number one has deployed in this instance and that the plane is in fact on the ground?
Then the A320 should either be benign and totally lend itself to complete pilot control of all systems instantaneously or actively recognize that a full stop is the only option and bring all its facilities to bear to assist the pilots to bring the aircraft to a full stop. Would this line of thinking be wrong?
I have a lot of respect for you gentlemen up front when I am an SLF (which was very frequent) and am always thankful for a job well done. I am concerned when relatively minor errors can result in an accident of this magnitude. Especially when a maker such as Airbus with its motto of protecting the airplane from human error has so obviously failed to do so here. And that such an exact situ has already occurred and insufficient action was taken to avoid a repeat. (my less then 2 cents)
Did the A320's electronic brain (if you will) fail to recognize that reverser number one has deployed in this instance and that the plane is in fact on the ground?
Then the A320 should either be benign and totally lend itself to complete pilot control of all systems instantaneously or actively recognize that a full stop is the only option and bring all its facilities to bear to assist the pilots to bring the aircraft to a full stop. Would this line of thinking be wrong?
I have a lot of respect for you gentlemen up front when I am an SLF (which was very frequent) and am always thankful for a job well done. I am concerned when relatively minor errors can result in an accident of this magnitude. Especially when a maker such as Airbus with its motto of protecting the airplane from human error has so obviously failed to do so here. And that such an exact situ has already occurred and insufficient action was taken to avoid a repeat. (my less then 2 cents)
Last edited by armchairpilot94116; 8th Aug 2007 at 02:09.
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armchair - the issue is that this is not a 'relatively minor error'. This is a huge, gross error. Perhaps it was easily made, but it is as gross an error as stamping on the gas pedal in your car when you meant to hit the brakes. Gross errors lead to gross consequences no matter who builds the aircraft.
From the 737Ng FCOM
During landing, the auto speed brake system operates when these conditions
occur:
• SPEED BRAKE lever is in the ARMED position
• SPEED BRAKE ARMED light is illuminated
• radio altitude is less than 10 feet
• landing gear strut compresses on touchdown
Note: Compression of any landing gear strut enables the flight spoilers to
deploy. Compression of the right main landing gear strut enables the
ground spoilers to deploy.
• both thrust levers are retarded to IDLE
• main landing gear wheels spin up (more than 60 kts).
The SPEED BRAKE lever automatically moves to the UP position and the
spoilers deploy.
If the SPEED BRAKE lever is in the DOWN position during landing or rejected
takeoff, the auto speed brake system operates when these conditions occur:
• main landing gear wheels spin up (more than 60 kts)
• both thrust levers are retarded to IDLE
• reverse thrust levers are positioned for reverse thrust.
The SPEED BRAKE lever automatically moves to the UP position and spoilers
deploy.
So obviously Boeing do not think this scenario should be protected against!
During landing, the auto speed brake system operates when these conditions
occur:
• SPEED BRAKE lever is in the ARMED position
• SPEED BRAKE ARMED light is illuminated
• radio altitude is less than 10 feet
• landing gear strut compresses on touchdown
Note: Compression of any landing gear strut enables the flight spoilers to
deploy. Compression of the right main landing gear strut enables the
ground spoilers to deploy.
• both thrust levers are retarded to IDLE
• main landing gear wheels spin up (more than 60 kts).
The SPEED BRAKE lever automatically moves to the UP position and the
spoilers deploy.
If the SPEED BRAKE lever is in the DOWN position during landing or rejected
takeoff, the auto speed brake system operates when these conditions occur:
• main landing gear wheels spin up (more than 60 kts)
• both thrust levers are retarded to IDLE
• reverse thrust levers are positioned for reverse thrust.
The SPEED BRAKE lever automatically moves to the UP position and spoilers
deploy.
So obviously Boeing do not think this scenario should be protected against!
Armchairpilot,
Once the reversers are deployed, you should continue with the landing. But you should not be excluded from other actions by a "logic system", because one day you might, in an emergency, want to do different.
I'm afraid I don't know what happened with the spoilers in this particular accident.
As ELAC more eloquently pointed out, failing to move the thrust levers to idle on landing is about as major an error as just pushing the sidestick forwards until you hit the ground. In car terms, reversing instead of going forwards (when there is a cliff behind you).
Once the reversers are deployed, you should continue with the landing. But you should not be excluded from other actions by a "logic system", because one day you might, in an emergency, want to do different.
I'm afraid I don't know what happened with the spoilers in this particular accident.
am concerned when relatively minor errors can result in an accident of this magnitude
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Right Way Up,
two things here, really one remark and one question:
In a Boeing (or any airplane with thrust levers that move with autothrust settings), on an approach flown with autothrust, what positions will the TLs be in if the pilot does not manually retard in the flare?
Will they be in a position that satisfies the spoilers/speedbrakes clauses? My impression is that the answer is yes.
Also: in the 737NG, is there a manual override for the spoiler/speedbrake logic? That is, can the crew manually deploy at least part of the spoilers in case of a malfunction of the automatic system?
pj
two things here, really one remark and one question:
In a Boeing (or any airplane with thrust levers that move with autothrust settings), on an approach flown with autothrust, what positions will the TLs be in if the pilot does not manually retard in the flare?
Will they be in a position that satisfies the spoilers/speedbrakes clauses? My impression is that the answer is yes.
Also: in the 737NG, is there a manual override for the spoiler/speedbrake logic? That is, can the crew manually deploy at least part of the spoilers in case of a malfunction of the automatic system?
pj