LOT 737 incident, June 2007: crew's poor English blamed
My understanding from the report is that they fast aligned the IRS at the gate. The FO being used to entering E for east rather W for west (automation error due to LOT's route structure) put in a position two degrees too far to the east. Due to the lattitude being correct and the longitude relatively close, after probably showing an error message, it appeared to have accepted the data, e.g. no blank screens or warning flags.
At the holding point they realised that something looked wrong with the Nav display and tried to re-enter their position, but then made the situation worse by not reselecting Nav mode. When TOGA was pushed the screens then blanked. This was noticed too late.
The crew told another story about mobile phone interference etc. But as the AAIB notes the recorded data and the pilot's reports do not agree.
It reminds me of a story, which originally I did not fully understand, of a crew many years ago achieving something similar by re-entering the wrong position several times and then having to fly back from Egypt on radar vectors and raw data, after at least getting the attitude data back. Interesting to note that something similar has happened at Easy and probably others too. Hopefully we can all learn from this.
At the holding point they realised that something looked wrong with the Nav display and tried to re-enter their position, but then made the situation worse by not reselecting Nav mode. When TOGA was pushed the screens then blanked. This was noticed too late.
The crew told another story about mobile phone interference etc. But as the AAIB notes the recorded data and the pilot's reports do not agree.
It reminds me of a story, which originally I did not fully understand, of a crew many years ago achieving something similar by re-entering the wrong position several times and then having to fly back from Egypt on radar vectors and raw data, after at least getting the attitude data back. Interesting to note that something similar has happened at Easy and probably others too. Hopefully we can all learn from this.
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Unfortunately I have to mention an incident in Poland,
(no English knowledge involved)
where a CPT on a night IFR flight on ATR72 experiencing some
abnormalities and errors in HSI told the Copilot to "Reset it !",
resulting in total failure of systems and loss of spatial orientation.
They recovered and broke out of clouds using stand-by instruments,
came to straight and level, readjusted instruments and completed flight,
but in the process reached 2.6G almost disintegrating the AC.
Preliminary report here, unfortunately in Polish,
but visualisations available.
http://www.mi.gov.pl/2-4823096e55b13-1786572-p_1.htm
(click on: "Wizualizacja ścieżki..." and "Wizualizacja manewru..." to download)
This time no ATC support was available to help in recovery...
(no English knowledge involved)
where a CPT on a night IFR flight on ATR72 experiencing some
abnormalities and errors in HSI told the Copilot to "Reset it !",
resulting in total failure of systems and loss of spatial orientation.
They recovered and broke out of clouds using stand-by instruments,
came to straight and level, readjusted instruments and completed flight,
but in the process reached 2.6G almost disintegrating the AC.
Preliminary report here, unfortunately in Polish,
but visualisations available.
http://www.mi.gov.pl/2-4823096e55b13-1786572-p_1.htm
(click on: "Wizualizacja ścieżki..." and "Wizualizacja manewru..." to download)
This time no ATC support was available to help in recovery...
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Ptkay you forgot to mention ERJ-145 out from GDN
See http://www.ulc.gov.pl/_download/bezp...kat_131-05.pdf
See http://www.ulc.gov.pl/_download/bezp...kat_131-05.pdf
For a start hopefully some of us might learn a bit of humility. Maybe part of the problem is thinking after 15 years flying the same machine nothing can go wrong.
Maybe I am being a bit unfair lomapaseo, but your comment also sounds a bit a bit warm and fireside like, if you understand the CRM reference.
I now know of three very experienced captains this has happened to on the 737 in large well established airlines. What do you think we might learn?
I am pleased to see that others have started the ball rolling.
Maybe I am being a bit unfair lomapaseo, but your comment also sounds a bit a bit warm and fireside like, if you understand the CRM reference.
I now know of three very experienced captains this has happened to on the 737 in large well established airlines. What do you think we might learn?
I am pleased to see that others have started the ball rolling.
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Originally Posted by lc_aerobatics
Ptkay you forgot to mention ERJ-145 out from GDN
See http://www.ulc.gov.pl/_download/bezp...kat_131-05.pdf
See http://www.ulc.gov.pl/_download/bezp...kat_131-05.pdf
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Due to poor english
- ATC selecting wrong method of separation, horizontal, instead of vertical
- ATC giving command to EMB170 to sink from FL270 to 2700ft, when EMB 145 was climbing to FL210
- ATC lack of effective actions to secure separation when recognizing conflict (not using word "immediately")
I don't see any relation to "poor english"...
Just poor performance and poor judgement of the ATC...
Take me downwind
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Polish pilots' poor English almost led to crash
A Polish airliner came within seconds of colliding with another plane near Heathrow because its pilots had such poor English that they could not understand basic instructions from air traffic controllers. The Lot Boeing 737, carrying 95 passengers and crew, wandered the skies for almost half an hour as the pilots struggled to identify their position. A controller had to instruct another aircraft to change direction to avoid a collision.
A document seen by The Times suggests that only 15 out of 800 Polish pilots flying internationally have passed the test for the required standard of English.
The two pilots in the Heathrow incident had to rely on directions after positioning instruments went blank because of a co-pilot’s error. They repeatedly failed to comply with instructions as they tried to return to Heathrow. On the final approach the Boeing appeared to be heading for the wrong runway, prompting a controller to order other aircraft to leave the area.
The incident, described in a report by the Air Accidents Investigation Branch (AAIB), highlights the risks associated with having so many foreign pilots with only rudimentary English using British airports. English is the international language of aviation but many countries failed to comply with the International Civil Aviation Organisation (ICAO) deadline of March this year for ensuring that their pilots were proficient in the language.
Poland has applied to the ICAO for an exemption until March 2011, the last possible date for compliance, after which pilots without the required level could be banned from international airspace. In a letter to the ICAO obtained by The Times, the Polish government’s civil aviation office suggests that only 15 pilots out of 800 Poles flying international routes have passed the appropriate English test.
The letter, sent on March 4, nine months after the Heathrow incident, states: “We haven’t had any accident caused by insufficient English level as well as [sic] we have not received any information from air traffic control agencies that Polish pilots were not able to communicate correctly. Therefore, potential risk of accident occurrence due to lack of English language proficiency is very improbable.”
That claim is contradicted by the AAIB’s investigation, which said: “The crew of Lot 282 were not able to communicate adequately the nature and extent of their problem.” The report added: “The commander, who was making the radio calls, was not able to understand some of the instructions.”
The AAIB found that an initial error by the co-pilot had been “compounded by the difficulty of obtaining information from the pilots because of their limited command of English”.
The Department for Transport confirmed that it had kept the Polish authorities informed of the investigation.
David Learmount, safety editor of Flight International magazine, said that it was very worrying that the pilots had not understood British controllers. “It could have been even worse if they had been trying to understand a French controller speaking to them in English,” he said.
“Countries which did not previously have many international pilots are now flooding the world with flights piloted by people who can’t speak English properly. For many pilots, learning English is much more difficult than learning to fly.”
A document seen by The Times suggests that only 15 out of 800 Polish pilots flying internationally have passed the test for the required standard of English.
The two pilots in the Heathrow incident had to rely on directions after positioning instruments went blank because of a co-pilot’s error. They repeatedly failed to comply with instructions as they tried to return to Heathrow. On the final approach the Boeing appeared to be heading for the wrong runway, prompting a controller to order other aircraft to leave the area.
The incident, described in a report by the Air Accidents Investigation Branch (AAIB), highlights the risks associated with having so many foreign pilots with only rudimentary English using British airports. English is the international language of aviation but many countries failed to comply with the International Civil Aviation Organisation (ICAO) deadline of March this year for ensuring that their pilots were proficient in the language.
Poland has applied to the ICAO for an exemption until March 2011, the last possible date for compliance, after which pilots without the required level could be banned from international airspace. In a letter to the ICAO obtained by The Times, the Polish government’s civil aviation office suggests that only 15 pilots out of 800 Poles flying international routes have passed the appropriate English test.
The letter, sent on March 4, nine months after the Heathrow incident, states: “We haven’t had any accident caused by insufficient English level as well as [sic] we have not received any information from air traffic control agencies that Polish pilots were not able to communicate correctly. Therefore, potential risk of accident occurrence due to lack of English language proficiency is very improbable.”
That claim is contradicted by the AAIB’s investigation, which said: “The crew of Lot 282 were not able to communicate adequately the nature and extent of their problem.” The report added: “The commander, who was making the radio calls, was not able to understand some of the instructions.”
The AAIB found that an initial error by the co-pilot had been “compounded by the difficulty of obtaining information from the pilots because of their limited command of English”.
The Department for Transport confirmed that it had kept the Polish authorities informed of the investigation.
David Learmount, safety editor of Flight International magazine, said that it was very worrying that the pilots had not understood British controllers. “It could have been even worse if they had been trying to understand a French controller speaking to them in English,” he said.
“Countries which did not previously have many international pilots are now flooding the world with flights piloted by people who can’t speak English properly. For many pilots, learning English is much more difficult than learning to fly.”
There was a pathetically written summary of the Heathrow incident on BBC Teletext yesterday, the day this came out. Not only did they, as ever, completely invent that there had been a "near miss" with another aircraft, which is pure fiction, but then stated that the aircraft returned to Heathrow by the FO using standby instruments, which if you read the report is stated to be the one thing that didn't happen.
Now then BBC, that's really poor English !
Now then BBC, that's really poor English !
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WHBM: "then stated that the aircraft returned to Heathrow by the FO using standby instruments, which if you read the report is stated to be the one thing that didn't happen."
I read the report. The aircraft returned to Heathrow. FO was PF. They were using standby instruments. What have I missed?
I read the report. The aircraft returned to Heathrow. FO was PF. They were using standby instruments. What have I missed?
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WHBM
I have watched thie incident twice on radar replay whilst listening to the actual R/T.
The pilots were using standby instruments - unfortunately there were a few problems with this:
1. - They did not communicate the fact they were using standby instruments to the ATCO - either because of stress - you could hear the very high level of stress in their voices, or because they did not think to do so.
2. - ATCOs are generally unaware of the difficulties of flying on standby instruments - I used to fly in the mil, have practised loss of main instruments extensively in the course of that career. However something I have learned from this thread is that in some modern passenger airliners, the layout of the standby instruments leaves a lot to be desired - i.e. the difficulty of keeping a tight scan between the compass and the AI.
Is this a problem with just the B737, or is it the same for all modern aircraft? I don't know and it's not right to expect any ATCO to know the instrument layout of every aircraft they may control - that why pilots need to speak up in these situations.
As has been mentioned a few times, including by myself, in situatons like these, maybe the best option would be turns initiated by the ATCO, i.e. the 'no compass, no gyro' procedure.
The problem with the above statement is I think trying to get that idea across to this particular crew in this instance would have been very difficult - partly due to poor English, partly due to the lack of mental capacity they had at the time due stress, an partly because it seems that to most pilots who have not had much experience ouside modern airliners, the 'no compass, no gyro' procedure is unknown to them.
The BBC were not the only ones who made mistakes in their report - the Telegraph report linked in the first post of this thread is littered with errors as well - a supposedly 'good quality' newspaper!
I have watched thie incident twice on radar replay whilst listening to the actual R/T.
The pilots were using standby instruments - unfortunately there were a few problems with this:
1. - They did not communicate the fact they were using standby instruments to the ATCO - either because of stress - you could hear the very high level of stress in their voices, or because they did not think to do so.
2. - ATCOs are generally unaware of the difficulties of flying on standby instruments - I used to fly in the mil, have practised loss of main instruments extensively in the course of that career. However something I have learned from this thread is that in some modern passenger airliners, the layout of the standby instruments leaves a lot to be desired - i.e. the difficulty of keeping a tight scan between the compass and the AI.
Is this a problem with just the B737, or is it the same for all modern aircraft? I don't know and it's not right to expect any ATCO to know the instrument layout of every aircraft they may control - that why pilots need to speak up in these situations.
As has been mentioned a few times, including by myself, in situatons like these, maybe the best option would be turns initiated by the ATCO, i.e. the 'no compass, no gyro' procedure.
The problem with the above statement is I think trying to get that idea across to this particular crew in this instance would have been very difficult - partly due to poor English, partly due to the lack of mental capacity they had at the time due stress, an partly because it seems that to most pilots who have not had much experience ouside modern airliners, the 'no compass, no gyro' procedure is unknown to them.
The BBC were not the only ones who made mistakes in their report - the Telegraph report linked in the first post of this thread is littered with errors as well - a supposedly 'good quality' newspaper!
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Anotherthing - I think its the same problem on both sides. Pilots theoretically should be able to fly using standby instruments, but how many of them actually ever do that? Same for ATCOs - at my place "non gyro" is a standard part of simulator training for prospective approach radar controllers, but how many of them actually ever have the opportunity to use it? And moreover, during training you know it will be non-gyro, and the "pilot" reports he has no instruments. This was not the case here, and I don't think many controllers would understand what flying on standby instruments mean.
And an interesting note - maybe the stress was caused by the fact they faced an unusual situation, but which in fact they thought should be easy to handle, just to find out otherwise. Engine fires, bird strikes etc. - all much gravier, but everyone practice them, here a/c was flyable, and they found they can't handle it.
And an interesting note - maybe the stress was caused by the fact they faced an unusual situation, but which in fact they thought should be easy to handle, just to find out otherwise. Engine fires, bird strikes etc. - all much gravier, but everyone practice them, here a/c was flyable, and they found they can't handle it.
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Thank you.
Originally Posted by sitigetfel
(BTW: ...they were not even invited to the Victory Parade after the war, not to disturb Uncle Jo)
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Damn right...
Originally Posted by groundfloor
Don`t want to detract from the seriousness but hey these are not the first Polish pilots flying around London with limited english skills.....
1940?
1940?
Last edited by Ptkay; 13th Jun 2008 at 12:52.
lomapaseo said:
After reading the report, three things seem glaringly obvious:
1. With an instrument failure of this seriousness, if you are in VMC, don't climb into the clouds.
2. There should have been a more informed handoff to the approach controller
3. "Somebody" should have been at the stand when they returned in order to pull the CVR breaker.
And what should we learn?
1. With an instrument failure of this seriousness, if you are in VMC, don't climb into the clouds.
2. There should have been a more informed handoff to the approach controller
3. "Somebody" should have been at the stand when they returned in order to pull the CVR breaker.
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Originally Posted by PTKay
I can give you an example of my friend who has had his final interview by LOT today
and (hopefully) will take a right seat soon.
and (hopefully) will take a right seat soon.
My friend was successful yesterday at his interview by LOT and starts the job in August, in the right seat of EBR170.
And yes, he passed the ICAO Language Proficiency test on Level 5 !!!
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"... the ICAO Language Proficiency Test"
Good to hear that your friend passed his test, but which test was it?
There are a good number flying around..
Was it as rigourous as the ELPAC for ATCOs?
There are a good number flying around..
Was it as rigourous as the ELPAC for ATCOs?