LOT 737 incident, June 2007: crew's poor English blamed
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LOT 737 incident, June 2007: crew's poor English blamed
The AAIB has issued a report into an incident last June, in which a LOT 737-500, "meandered helplessly" (to quote the Daily Telegraph) after takeoff from LHR, due to communications problems between the aircraft and ATC.
http://www.telegraph.co.uk/travel/tr...tructions.html
http://www.aaib.dft.gov.uk/cms_resou...KA%2006-08.pdf
http://www.telegraph.co.uk/travel/tr...tructions.html
http://www.aaib.dft.gov.uk/cms_resou...KA%2006-08.pdf
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Indeed, NoD, merely 'observations' as per the norm. It would appear that a far simpler root problem lay behind this, possibly taking off with the IRS's in ALIGN or OFF?
EDIT to add praise for a neat bit of controlling by ATC!
EDIT to add praise for a neat bit of controlling by ATC!
Last edited by BOAC; 12th Jun 2008 at 08:40.
Whilst there is no allocation of blame, the facts do not appear to reflect positively on the crew. As a 737 captain I am always particularly interested in incidents I can learn from. Hopefully I can subsequantly avoid doing something similar. The Adam Air 737 crew messing with the IRS and crashing, the TNT 737 crew trying to continue an autoland after deselecting the autopilot below 800 feet are good recent examples.
In this case a highly experienced crew (captain 15 years on type, co-pilot 6) managed to get into pretty serious difficulty doing something I can barely imagine. Taking off with the IRS not aligned and therefore no primary attitude or navigation displays is pretty amazing. That you can appear to have aligned the IRS, with most of the displays then disappearing on takeoff (if that is really what happened) is a sobering thought. In any case it underlines the rule about not moving the aircraft before the IRS are aligned, if it needed underlining.
The report is pretty fair in pointing out that the crew were under a fair amount of stress which may have exacerbated their limited English. But their level of English was a secondary problem. What is clear is that they were completely unable to navigate the aircraft on their own for various reasons. Without help from ATC it is unlikely they would have found the runway.
In this case a highly experienced crew (captain 15 years on type, co-pilot 6) managed to get into pretty serious difficulty doing something I can barely imagine. Taking off with the IRS not aligned and therefore no primary attitude or navigation displays is pretty amazing. That you can appear to have aligned the IRS, with most of the displays then disappearing on takeoff (if that is really what happened) is a sobering thought. In any case it underlines the rule about not moving the aircraft before the IRS are aligned, if it needed underlining.
The report is pretty fair in pointing out that the crew were under a fair amount of stress which may have exacerbated their limited English. But their level of English was a secondary problem. What is clear is that they were completely unable to navigate the aircraft on their own for various reasons. Without help from ATC it is unlikely they would have found the runway.
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NoD
It depends what your exact idea is of primary causes etc.
The primary cause may well have nothing to do with the standard of English in this incident - the primary cause was in fact more likely to be down to the non alignement of IRS (coupled with the fact that the crew did not ralise this).
What was a major factor in the resultant way the incident played out was the poor English - exacerbated no doubt by the stress the crew were experiencing.
In this respect, the poor English was a primary factor (and some would argue it was the main factor by a long way) in the way the incident snowballed.
I have listened to the actual R/T and watched the radar replays twice now - I can assure you that had communications been clearer, the incident would not have caused so much of a problem.
It depends what your exact idea is of primary causes etc.
The primary cause may well have nothing to do with the standard of English in this incident - the primary cause was in fact more likely to be down to the non alignement of IRS (coupled with the fact that the crew did not ralise this).
What was a major factor in the resultant way the incident played out was the poor English - exacerbated no doubt by the stress the crew were experiencing.
In this respect, the poor English was a primary factor (and some would argue it was the main factor by a long way) in the way the incident snowballed.
I have listened to the actual R/T and watched the radar replays twice now - I can assure you that had communications been clearer, the incident would not have caused so much of a problem.
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I have not seen in the report any reference to the enormous complication caused by compass acceleration/turning errors which would have made reading an accurate heading very difficult. A timely reminder, perhaps of the need for gentle handling when using the standby compass? As the report says, there is an over-reliance on the FMS/IRS in aviation and 'standby' skills are no doubt sadly lacking.
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interestingly an easyjet 737 did exactly the same thing at Luton several years ago. Training Capt, SO under initial line training - fast align attempted at A1, forgot to select nav, only saw the lack of ND at 80kts, airborne into IMC.
Not a good situation. Flying on those rubbish Standby Inst is pretty difficult.
Not a good situation. Flying on those rubbish Standby Inst is pretty difficult.
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anotherthing
Your points are of course valid, but it depends "where / when / what aspects" you think this incident was "serious".
I will presume you are an ATCO... and to you the incident was "serious" because there was an aircraft wandering around the LTMA that either could not or would not follow headings. To an ATCO that is very serious...
As a pilot, this was somewhat less so... the aircraft had good endurance, and I am sure you guys would have kept things out if it's way, albeit with extensive disruption to other traffic. Apart from "how" they got into this scenario, nobody (crew included) seemed to work out how hard it is to fly a fast aircraft using a mickey mouse small compass, and located far from the (Sby) AI. It was the second ATCO who picked up on this I think and went for the timed turns? Good on him...
Language played a part no doubt, but how many of our "newer" pilots (and ATCOs?) are trained in timed turns / no compass procedures? I've done 12+ years in the airlines, and never flown either the simulator or the aircraft on a liquid compass
As the AAIB observed, having got into that situation, it would require exceptional crew co-ordination to fly accurately - they fact they flew altitudes and altitude changes well shows at least the priority was directed correctly... heading I'm afraid comes a distinct second.
NoD
Your points are of course valid, but it depends "where / when / what aspects" you think this incident was "serious".
I will presume you are an ATCO... and to you the incident was "serious" because there was an aircraft wandering around the LTMA that either could not or would not follow headings. To an ATCO that is very serious...
As a pilot, this was somewhat less so... the aircraft had good endurance, and I am sure you guys would have kept things out if it's way, albeit with extensive disruption to other traffic. Apart from "how" they got into this scenario, nobody (crew included) seemed to work out how hard it is to fly a fast aircraft using a mickey mouse small compass, and located far from the (Sby) AI. It was the second ATCO who picked up on this I think and went for the timed turns? Good on him...
Language played a part no doubt, but how many of our "newer" pilots (and ATCOs?) are trained in timed turns / no compass procedures? I've done 12+ years in the airlines, and never flown either the simulator or the aircraft on a liquid compass
As the AAIB observed, having got into that situation, it would require exceptional crew co-ordination to fly accurately - they fact they flew altitudes and altitude changes well shows at least the priority was directed correctly... heading I'm afraid comes a distinct second.NoD
BOAC, indeed. I remember how I hated compass turns because you better not look at the compass to determine the initial direction of the turn. If you fly 090° compass heading, 120° heading is on the left of the lubber line. You had to visualise a compass rose in your head. If you don't do that, you're bound to turn in the wrong direction and lose all situational awareness. You're lost before you know it...
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NoD
Thats a fair point - I used to fly for the mil before becoming a civvy ATCO - one of the things I questioned as soon as I saw the incident for the first time, (and before we 'analysed' it), was why the ATCO did not use a "no compass, no gyro" procedure earlier, as soon as it was apparent that headings were not being flown- something we practiced from both sides of the microphonne extensively in the military.
I suppose as technology 'advances' we lose a lot of the skills we used to have, or we discard them as they are very unlikely to be needed and there are more pressing things that need to be practiced with the advent of new equipment/technology.
If the English spoken by the crew in this incident had been better, there is no doubt in my mind that the incident (from an ATC and an incident management point of view) would have been resolved much earlier and better.
The breakdown of communication was IMHO a major factor in so much that the inability of the crew to communicate, (and/or the inability of the ATCO to understand), the implications caused much more stress on the flight deck than there should have been thus reducing their mental capacity and therefore the fault diagnosis etc.
The fact the aircraft was not keeping to assigned altitudes (within the tolerances required for seperation purposes for ATCOs) was also a worry on a couple of occasions.
You are correct, as ATCOs we would keep other aircraft out of the way - but when you have departures that fly under holding areas it is difficult and often impossible to notice quickly if they are deviating from the SID route or heading - especially when the crew themselves are not aware and thus unable to warn you... it is extremely difficult in the LTMA to de-conflict flights without having a massive knock on effect - as you can imagine, the LOT may have been in conflict with a couple of flights, so they would be given vectors to keep them clear... however because of the confines of airspace, these aircraft themselves then become conflictors for another set of aircraft, and so on!
I think that in situations like these, it wold be far better for the ATCO to take control of navigation and introduce timed turns - there will still be plenty of scope within this procedure for the crew to try to diagnose the fault.
As an aside - there were a lot of other lessons from an ATC point of view to be learned - one of the ATCOs involved made a few assumptions that were not particularly smart - however the incident did turn out OK, and thanks to the way the UK system works, it has provided us with a good lesson learning experience.
Thats a fair point - I used to fly for the mil before becoming a civvy ATCO - one of the things I questioned as soon as I saw the incident for the first time, (and before we 'analysed' it), was why the ATCO did not use a "no compass, no gyro" procedure earlier, as soon as it was apparent that headings were not being flown- something we practiced from both sides of the microphonne extensively in the military.
I suppose as technology 'advances' we lose a lot of the skills we used to have, or we discard them as they are very unlikely to be needed and there are more pressing things that need to be practiced with the advent of new equipment/technology.
If the English spoken by the crew in this incident had been better, there is no doubt in my mind that the incident (from an ATC and an incident management point of view) would have been resolved much earlier and better.
The breakdown of communication was IMHO a major factor in so much that the inability of the crew to communicate, (and/or the inability of the ATCO to understand), the implications caused much more stress on the flight deck than there should have been thus reducing their mental capacity and therefore the fault diagnosis etc.
The fact the aircraft was not keeping to assigned altitudes (within the tolerances required for seperation purposes for ATCOs) was also a worry on a couple of occasions.
You are correct, as ATCOs we would keep other aircraft out of the way - but when you have departures that fly under holding areas it is difficult and often impossible to notice quickly if they are deviating from the SID route or heading - especially when the crew themselves are not aware and thus unable to warn you... it is extremely difficult in the LTMA to de-conflict flights without having a massive knock on effect - as you can imagine, the LOT may have been in conflict with a couple of flights, so they would be given vectors to keep them clear... however because of the confines of airspace, these aircraft themselves then become conflictors for another set of aircraft, and so on!
I think that in situations like these, it wold be far better for the ATCO to take control of navigation and introduce timed turns - there will still be plenty of scope within this procedure for the crew to try to diagnose the fault.
As an aside - there were a lot of other lessons from an ATC point of view to be learned - one of the ATCOs involved made a few assumptions that were not particularly smart - however the incident did turn out OK, and thanks to the way the UK system works, it has provided us with a good lesson learning experience.
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Whilst there is no allocation of blame, the facts do not appear to reflect positively on the crew
Well if you liked my turn of phrase you may (as Amazon says) also be interested in the following snippet from the AAIB's report:
There were two main sources of information regarding
the events on this flight: the recorded data and the reports
from the pilots. In some respects, the information from the
two sources was not consistent.the events on this flight: the recorded data and the reports
from the pilots. In some respects, the information from the
It is also clear that the incident reinforces the need for an improvement in levels of English. I saw an amazing programme on TV recently, where they went up to non european captains at Frankfurt airport and tried to talk to them in English. The response on camera, along the lines of 'sorry my English, she not very good' would be comic were it not obviously such a serious problem.
Last edited by lederhosen; 12th Jun 2008 at 12:55.
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Yes, gents, you are right, it was a major c... up by the crew.
But I would like to put my twopence worth to the case.
I used to be a scientist and all the conferences we attended were held in English...
Or I would say a "I-English", which term I use to describe the "international, English-like language common to the scientific world".
I can tell you, the biggest trouble at any conference was when a native speaking British or American scientist was holding a speech.
Nobody could follow. They used UK-English, or US-English, but no I-English.
It was much easier to understand a Danish, Polish, German or whatever accent English,
than native speakers.
I assume similar trouble in the ATC-PIC communications...
But it was on a side note.
Another side note is, that the times of "non-English speaking, hard on electronic gizmo and hard on floating compass" pilots in LOT are over.
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.
1. He is fluent in English, crazy on ATC simms, spending hours a day
talking ATC simm... (he originally wanted to be an ATC controller).
2. He is fluent in FMS, NAVS etc., he is a computer freak, he build
a full size B737 simulator together with a friend in his attic (no move of course)
3. He used to build up his time flying An-2, all the time with shaky,
liquid compass, some times IMC when bringing sky jumpres to the altitude.
So this is the new generation, maybe no 15.000 hours, maybe no 9.000 on type,
but growing up in modern world, and still getting enough of his
basic flying skills in real world.
And on the bottom line:
the old generation LOT pilots may not speak fluent English,
but they certainly speak fluent Russian....
But I would like to put my twopence worth to the case.
I used to be a scientist and all the conferences we attended were held in English...
Or I would say a "I-English", which term I use to describe the "international, English-like language common to the scientific world".
I can tell you, the biggest trouble at any conference was when a native speaking British or American scientist was holding a speech.
Nobody could follow. They used UK-English, or US-English, but no I-English.
It was much easier to understand a Danish, Polish, German or whatever accent English,
than native speakers.
I assume similar trouble in the ATC-PIC communications...
But it was on a side note.
Another side note is, that the times of "non-English speaking, hard on electronic gizmo and hard on floating compass" pilots in LOT are over.
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.
1. He is fluent in English, crazy on ATC simms, spending hours a day
talking ATC simm... (he originally wanted to be an ATC controller).
2. He is fluent in FMS, NAVS etc., he is a computer freak, he build
a full size B737 simulator together with a friend in his attic (no move of course)
3. He used to build up his time flying An-2, all the time with shaky,
liquid compass, some times IMC when bringing sky jumpres to the altitude.
So this is the new generation, maybe no 15.000 hours, maybe no 9.000 on type,
but growing up in modern world, and still getting enough of his
basic flying skills in real world.
And on the bottom line:
the old generation LOT pilots may not speak fluent English,
but they certainly speak fluent Russian....
Last edited by Ptkay; 13th Jun 2008 at 14:21.
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Not playing down the importance of flight and crew having to be able to speak English but I was alwys taught in CRM sessions that no matter how good your english is, when it's not somebodies mother tongue that when encountering a stressfull situation the brain will always revert to the speakers mother tongue to be able to focus more on the actual problem. Maybe the captains english was good enough in normal day to day situations, this incident made it probably a lot harder for im to understand and reply to simple instructions
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Their English didn't help, but the prominence given to it seems to me to be a product of the xenophobia of certain sections of the British media - an opportunity for the Torygraph to indulge in more Pole-bashing.
It does seem to me that the crew could be criticised for not declaring an emergency, but it doesn't take much English to say 'MAYDAY' so I don't think this was a language competence problem.
I also note that ATC on a couple of occasions said 'one eighty' or 'one hundred and eighty' rather than 'one eight zero', which may not have helped the crew's understanding.
It does seem to me that the crew could be criticised for not declaring an emergency, but it doesn't take much English to say 'MAYDAY' so I don't think this was a language competence problem.
I also note that ATC on a couple of occasions said 'one eighty' or 'one hundred and eighty' rather than 'one eight zero', which may not have helped the crew's understanding.
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Poor English
Approximately ten years ago, I witnessed the take-off of an Il-76 operating for Heavylift. Turning the radio on, I heared the tower instructing them to turn right imediately after take-off. The reply, in perfect English was: turn right, confirmed, but their turn left in the direction of the only cloud over continental Europe hiding a B-737 on the landing pattern.
This is not he first time that I heard a pilot confirming that he would follow the direction given by the ATC but turns in the opposite direction.
This is not necessarily a language problem.
My twopences worth.
Willy.
This is not he first time that I heard a pilot confirming that he would follow the direction given by the ATC but turns in the opposite direction.
This is not necessarily a language problem.
My twopences worth.
Willy.
From bulletin's page 21:
So if I understood this correctly, the crew taxied and took off with blank EADIs, as shown on page 14?!?!? 
If it was indeed so, then their lack of english communication skills and difficulties with flying on standby instruments were not their greatest problems on that day.
Too bad they were past V1 
‘If the IRU data is Non Computed Data (NCD) as we assumed due to IRU being in ALIGN mode, EFIS will remove IRU related data but it will not display IRU related Flags on EADI or EHSI. With IRU data being NCD, EFIS will remove horizontal line, pitch lines, roll pointer and sky/ground shading from the EADI.
If it was indeed so, then their lack of english communication skills and difficulties with flying on standby instruments were not their greatest problems on that day.
Originally Posted by Dogma
Training Capt, SO under initial line training - fast align attempted at A1, forgot to select nav, only saw the lack of ND at 80kts, airborne into IMC.
