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The TNT B737 EMA/Birmingham incident thread

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Old 27th Jul 2006, 13:49
  #221 (permalink)  
 
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What really happened

An excellent investigative journal has been looking into this incident.

The 737 "bounced" over the "packed" terminal, hurtling towards the building before thundering over the roof.

Here's the link: http://www.thesun.co.uk/article/0,,2-2006340463,00.html

And here's a useful diagram of the flightpath that might help the AAIB:



So now you all know the truth!!
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Old 27th Jul 2006, 15:13
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So, other than a single report from a regional BBC website, can anybody actually confirm that they have been fired?
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Old 27th Jul 2006, 15:14
  #223 (permalink)  
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One would hope that a responsible employer would wait for the investigations to be completed before taking disciplinary procedures.
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Old 27th Jul 2006, 15:29
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Now that IS an interesting trajectory, being about 60 degrees in the wrong direction.
I would say that this rules out following side lobes of the ILS.
The most striking aspect of the black and white picture is....
The picture itself! It was made and posted by NutLoose on page 4 of this thread.
Apparently all these various investigation boards use PPRUNE as a source of information.

Last edited by fox niner; 27th Jul 2006 at 15:44.
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Old 27th Jul 2006, 15:41
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Check out the skid marks in the grass in this picture. they are about 5 degrees off-course compared to the runway heading. And not 60 degrees as claimed by the Sun...


Picture made by NutLoose:

http://mysite.orange.co.uk/il2skins/737_EGNX_copy.jpg
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Old 27th Jul 2006, 16:39
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If I've got it right, so far, the speculation is that, on a Cat3 autoland approach,the autopilot was inadvertently disengaged below re-engage height, then re-engaged, the ILS deviation wasn't monitored, the lack of correct annunciators was ignored, the correct references weren't available at decision and a go around wasn't initiated in sufficient time to avoid heavy ground contact.

I find that sequence too difficult to believe of two professional pilots.
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Old 27th Jul 2006, 17:42
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Unhappy

Originally Posted by Clarence Oveur
So, other than a single report from a regional BBC website, can anybody actually confirm that they have been fired?
Yes
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Old 27th Jul 2006, 18:42
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The Sun is talking absolute bullsh*t. When the rest of you get to hear what actually happened you won't be surprised about anything else.
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Old 27th Jul 2006, 18:55
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warm beer, about a month ago you also said they had been fired. Any reason why your information should be considered more reliable this time around?
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Old 27th Jul 2006, 20:12
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Most towers in the UK now monitor tracking and G/S. I'm surprised they didn't order a G/A when they became aware of the deviation. That and the fact that the pilots didn't initiate a G/A either makes one think it may all have happened very quickly?
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Old 27th Jul 2006, 20:56
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OK, so the crew somehow disconnected the A/P at 1.0 NM, which translates in an altitude of 300 feet. If I remember correctly, the 737 autopilot system introduces a nose-up trim at 400 ft agl. If you disconnect the A/P after this point, it will cause the airplane to fly up, and end up above the glideslope. Apparently this is what initially happened, see the preliminary findings report of the AAIB.
In order to reach the grass before the G/S antenna, after being somehow above the glideslope at one mile, they must have....pushed the controls into the ADI/EFIS. I wonder what the vertical speed was, and how the GPWS reacted to all this.


I found this photo of the OO-TND, which has a "CAT 1" placard installed in the cockpit! Does this mean the aircraft was CAT 1? could someone clarify this? picture taken 11 months before the accident.
http://www.jetphotos.net/viewphoto.php?id=511294

This mishap has the potential to become a classic, of which the aviation industry can learn a lot, whatever the findings will be.

Last edited by fox niner; 27th Jul 2006 at 21:22.
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Old 27th Jul 2006, 22:18
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Angry

Originally Posted by fox niner
Now that IS an interesting trajectory, being about 60 degrees in the wrong direction.
I would say that this rules out following side lobes of the ILS.
The most striking aspect of the black and white picture is....
The picture itself! It was made and posted by NutLoose on page 4 of this thread.
Apparently all these various investigation boards use PPRUNE as a source of information.
Nice of them to ask me wasn't it. If they had I might have made the unedited version available to them........... GRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR
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Old 1st Aug 2006, 12:09
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A team of pilots who crash landed a cargo plane at East
Midlands Airport, causing its runway to be closed for
several hours, have been sacked. Thousands of passengers
had to be moved to other airports after the cargo plane
landed on its nose at Birmingham Airport on 15 June
after first landing on the grass at East Midlands.
Cargo company TNT said despite the Belgian pilot showing
skill in his handling of the situation, the incident was
down to human error. The automatic pilot system was
disengaged due to a 'momentary lapse', and this lead to
the accident.
The aeroplane remained on the runway, causing all
take-offs to be cancelled for six hours and arrivals
only resuming in the afternoon. More than 200 flights
had to be diverted or were delayed.
The Air Accident Investigation Branch is investigating
but TNT said it operated a 'zero accident tolerance
level'.

http://www.uk-airport-news.info/
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Old 1st Aug 2006, 12:34
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Looks like news texts aren't copyrighted Almost exact the same text as in the BBC article http://news.bbc.co.uk/2/hi/uk_news/e...ds/5219956.stm , the link Nige321 posted on p. 12
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Old 1st Aug 2006, 12:35
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The Airport News article is the BBC article witha couple of words changed. As the BBC predates this I guess this is a rip-off and does not stand as additional corroboration of these guys having been sacked.

So does anyone have any authoritative evidence other than the BBC that this is what happened to them?

Sacking before the facts are out seems pretty unbelievable. ANyone work for TNT?
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Old 1st Aug 2006, 13:25
  #236 (permalink)  
 
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They have not been sacked. Yet. And that is a fact.
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Old 1st Aug 2006, 14:46
  #237 (permalink)  
 
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sugden:

"Sacking before the facts are out seems pretty unbelievable".

By that do you mean "before the AAIB report is published"? If so, I would be interested to know if you have a clause in YOUR contract that says that you can't be fired before the report is published.

Just because YOU don't know the facts does not mean that the facts are not known.
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Old 1st Aug 2006, 16:28
  #238 (permalink)  
 
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While we wait for the full analysis of the accident, it is disappointing to see possibly hasty punitive action taken in an industry that strives for a ‘just culture’ and the avoidance of blame. If nothing else, the industry deserves some public explanation, as without it the operator could be criticized for pre-judging the AAIB investigation or possible not conducting a thorough in-house investigation and thus overlooking any organizational contributions.
From a crew error viewpoint, I recall an interesting test – the substitution test.
CAP716 Aviation Maintenance Human Factors P159 www.caa.co.uk/docs/33/CAP716.PDF
The “substitution test” is good rule of thumb when illustrating where blame is inappropriate. If an incident occurs, ask yourself whether another similar individual (with the required skill, training and experience) in the same circumstances would have done anything different. If not, then blame is definitely inappropriate.“Do blame and punishment have a role in organisational risk management?”. Johnston, N. Flight Deck. Spring 1995, pp 33-6.
In addition, I would suggest that those who use this test require the appropriate level of ‘skill, training and experience’ in applying the human factors associated with error.

Applying the substitution test to the assumed initiating error - a ‘momentary lapse’ (a failure of execution – J. Reason) e.g. the disconnection of the autopilot vice use of transmit button, then it would be interesting to hear how many other 737 pilots have made or nearly made a similar mistake. Is the AP DISC button proud or guarded, is it easily depressed? Of course, any specific circumstances in this incident would also have to be considered, e.g. why it was necessary to transmit during the latter stages of a Cat3 approach, which could be a mitigating factor.

It is possible that many crews would judge the initiating factor as an error and therefore not blameworthy. However, if the test was applied to the subsequent autopilot re-engagement then a different judgment might be made. The crew action would have to be balance by the level of training given and understanding acquired about the use of the autopilot, the pressures of time, fuel, or fatigue. Alternatively if there was a clear cut company procedure that states – do not reconnect the autopilot in ‘these’ circumstances, then the ‘error’ could be judged a violation. But even violations have categories that require understanding and explanation, with many contributing factors originating from the organization.

And finally do you blame a crew for a violation that was precipitated by an error? The answer to this question requires both organizational judgment and wisdom.

I hope that the industry is not deprived of the opportunity to learn from this accident either by the operator’s opaque activities or by a limited investigation that does not delve into the human and organizational background to error.

If anyone has the document “Do blame and punishment have a role in organisational risk management?”. Johnston, N. ‘Flight Deck’. Spring 1995, pp 33-6. I would appreciate a copy.
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Old 1st Aug 2006, 22:39
  #239 (permalink)  
 
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Zero tolerance for accidents?!

So this airline has zero tolerance for accidents. Don't we all? Doesnt mean they have to trash careers without investigations being completed.
Reminds me of the Virgin pilot who allegedly "rang the bell" at Dulles just before Christmas a couple of years back. Fired without even a company hearing since he was banged up in USA with his passport locked away in a judges drawer in Leesburg. Lets have some compassion and process. None of us set out to scratch planes or passengers.
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Old 2nd Aug 2006, 07:57
  #240 (permalink)  
 
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Originally Posted by Oilhead
So this airline has zero tolerance for accidents. Don't we all? Doesnt mean they have to trash careers without investigations being completed.
Two points:
  1. A statement like 'this airline has zero tolerance for accidents' probably came from a 'bean-counter'. In a previous life I had an 'accident' with the same airline and it did not affect my status, salary or promotion. That was before it became a Belgian airline but I have no reason to believe anything has changed.
  2. Who said anything about 'trashing careers without investigation'? If you bother to read previous posts you will see that at least one source says 'They have not been sacked. Yet. And that is a fact.' Even if they have been 'sacked', I'm certain proper process would have been followed under European Company Law. A full Company investigation can take a matter of hours, not years like an AAIB report. If, FOR EXAMPLE, someone admitted that they had totally disregarded an SOP order NOT TO re-engage the A/P below a certain height AND totally disregarded an SOP TO go-around under certain circumstances, do you really expect that the company should keep them on full pay until such time that the AAIB come to the same inevitable conclusion?
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