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Ten to be indicted over TAM crash

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Old 27th Nov 2008, 16:01
  #41 (permalink)  
 
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Just with the purpose of enlightening our discussion I'm quoting a couple of paragraphs of a CAA paper 2004/10 called Flight Crew Reliance on Automation,writen by Mr.Simon Wood of Cranfield University

2 Crews of Highly Automated Aircraft Lose Manual Flying Skills
2.1 Summary
There has been very little research published on the subject of the change in manual
flying skill experienced by crews of highly automated aircraft. However, it is reported
consistently that there is a discernible reduction in manual flying skills that is
correlated both with the use of automation and whether the operation is long haul or
short haul.
2.2 Conclusion
The term “manual flying skills” is not fully defined and the loss of manual flying skills
is not covered by previous research.
2.3 Recommendations
Further investigation is required to establish; which skills are degraded, how can the
change be quantified and which pilot groups are affected.
A range of possible mitigating actions should be considered, including increased
practice, increased system reliability, safety reclassification of imposed manual flying
(e.g. to alert ATC), and increased automation training to avoid the necessity for
reversion to manual flight.
3 Inappropriate Response to Failures
3.1 Summary
3.1.1 Abnormal malfunctions have less well defined procedures compared with emergency
situations and therefore crew revert to knowledge-based behaviour requiring more
understanding of the system, plus time and effort to properly assess and resolve the
situation. This refocusing of tasks results in reduced levels of procedural
accomplishment, communications and situational awareness, i.e. relatively minor
failures can absorb both crew members in a way that is disproportionate to the
significance of the problem. Published aircraft procedures specifically do not include
elements of 'airmanship'.
3.1.2 System design is not always appropriate to keep pilots in the loop. (Research has
shown that rather than design systems to work on thresholds or specific limits for
control there should be a continuous flow of information to the pilot to indicate the
difficulty or increasing effort needed to keep relevant parameters on target.)
3.2 Conclusions
3.2.1 The current level of training does not adequately prepare crews to recognise or deal
with all situations that might arise.
3.2.2 Crews may fail to recognise failures because a) they do not have sufficient
understanding of 'normal' automated operation to be able to detect what is abnormal
and b) they do not receive training in recognition of situations from the symptoms as
they appear to the pilot. Thus they may not realise there is a problem or may believe
the problem is different to the real situation. Further, even when they do correctly
recognise the situation, they may not have sufficient system knowledge to respond
appropriately.
3.2.3 As noted under Risk 1 current training does not include practice at recognizing a
situation from the flight deck symptoms, for example, a programming input error or a
navigation database error. Frequency of recognition errors in accidents suggests that
such training would be justified.
3.3 Recommendation
Research should investigate practical ways of incorporating the cognitive elements of
CRM into automation training such that failure recognition and recovery are improved.
V
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Old 28th Nov 2008, 04:09
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Originally Posted by GlueBall
So, during the landing, flare and touchdown of this Fly By Wire A320 [where thrust levers are just "switches"] would your right hand be resting on your knee, or on the thrust levers. . . ? Or is this procedure altogether more complex than just that on the A320...?
Funny enough, early Airbus thinking (as confirmed by one very early operator here) was to do without thrust levers and replace them by … Push-Buttons !

But when you look at the following events, there are very serious questions to be asked :

Philippines
1998
One thrust reverser was deactivated before the flight.
Crew failed to retard one thrust lever upon landing.
The A320 continued past the runway end.

Taiwan
2004
One thrust reverser was deactivated before the flight.
Crew failed to retard one thrust lever upon landing.
The A320 continued past the runway end.

Brazil
2007
One thrust reverser was deactivated before the flight.
Crew failed to retard one thrust lever upon landing.
The A320 continued past the runway end.

Those are only the known cases that ended up with an accident.
Are there any other cases but with no bended aluminum at the end … I don’t know.
  • Does it mean other types don’t fly with a deactivated thrust reverser ?
  • Does it mean crews on other types are better trained for flying with a deactivated thrust reverser ?
  • Does it mean something in the A320 overall philosophy could insidiously facilitate that kind of situation ?

Pick up your own answer …
All I can say to Airbus FBW crews : Watch yourself, because Congonhas won’t be the last event of that specific type.
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Old 28th Nov 2008, 04:18
  #43 (permalink)  
 
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Easy fix

Then Airbus should modify the software to continue the voice generated callout "Retard, Retard. . . " until all thrust levers are physically retarded.
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Old 28th Nov 2008, 05:15
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If you guys havent read it, the congonhas crash thread is very indepth.

http://www.pprune.org/rumours-news/2...as-brazil.html
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Old 29th Nov 2008, 12:56
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Thanks armchairpilot.
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Old 29th Nov 2008, 20:27
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Originally Posted by GlueBall
Then Airbus should modify the software to continue the voice generated callout "Retard, Retard. . . " until all thrust levers are physically retarded
That’s the obvious for many … but not for the one concerned in the first place !?

That RETARD auto call out particularity was mentioned already in the 2000 official report following the first crash, it was again part of the Safety Recommendations after Taipei (interesting reading here and here) but nothing was done before Congonhas ...
Originally Posted by SPA83
When Airbus accepts the Taipei safety recommendation about a specific warning when one throttle is set to reverse while the other is above idle, but never send the service bulletin this is a fault
and I haven't seen anything mentioning a change since ...


Glueball, you mentioned insanity a few times regarding this TAM crew, but to me insanity is keeping doing things over and over when knowing they are wrong and in that perspective Airbus is insane not to have adapted that RETARD auto call out logic.

BTW is there anything in FCOM detailing the RETARD call out logic … ?
I would rate it as a very nice to know for pilots.
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Old 30th Nov 2008, 11:48
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CONF iture..
My FCOM (TRG ONLY) 1.31.10 says..

warning signal RETARD
condition THRUST LEVER NOT IN IDLE POSITION FOR LANDING
duration PERMANENT
silencing THRUST LEVER

No mention of silencing by A/T disengage which happens when reverse selected on one engine. Which would be nice to know...
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Old 3rd Dec 2008, 04:49
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Thanks TP, your training manual gives here as "many" details than the most up to date FCOM …

Originally Posted by armchairpilot94116
If you guys havent read it, the congonhas crash thread is very indepth.
TAM A320 crash at Congonhas, Brazil
Absolutely, very informative that huge thread of 130 pages.
All the contributors have produced a captivating reading and one year later there would still be a lot to say. I would like to comment on one of its posts #2295 on page 115

Originally Posted by PJ2
Before this accident, if someone has posited the scenario on PPRuNe, would you or anyone here have ever given creedance or even entertained the (wild) notion that thrust levers would/could possibly be left in any other position than idle, in any design, A or B, upon landing? I think not.
Sir, you are absolutely correct … but only as you fail to mention that Congonhas was already the third accident of the type. A trend developed already but 99% of the pilots around the world, including myself, and probably that implicated TAM crew, were kept ignorant of that once believed unconceivable mishap and its possible dire consequences … but Airbus knew and deliberately opted to ignore the very simple safety recommendation made after the second accident.


At that time Airbus faulted in two ways :
  1. They failed to publish at minimum an FCOM BULLETIN as subject : Landing with one deactivated Thrust Reverser
  2. They failed to implement the safety recommendation for a very simple alteration of the RETARD auto call out logic.
Strong of those two points, there was no Congonhas !

No chance the media will ever pick up on that. Far too serious for them and certainly not allowed to speak the truth anyway, but from the professionals on this forum, it is somehow disturbing not to feel more connivance and support in the name of safety.
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Old 4th Dec 2008, 09:39
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I don't fly the bus, but can one of you A320 left seaters please answer this question:

1- Where is your right hand during the flare/touchdown phase? In the case of one DMI'd reverser, would your hand/palm or fingers be on top of only one (1) thrust lever prior to retarding thrust. . . ?
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Old 4th Dec 2008, 10:40
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No, it would be on both thrust levers, as it would on any other approach. And one doesn't have to be a "left-seater" to do the landing in that situation. In the end it's the skipper's decision, but it's not mandatory for him/her to do the landing.
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Old 4th Dec 2008, 17:13
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CONF iture;
Sir, you are absolutely correct … but only as you fail to mention that Congonhas was already the third accident of the type. A trend developed already but 99% of the pilots around the world, including myself, and probably that implicated TAM crew, were kept ignorant of that once believed unconceivable mishap and its possible dire consequences … but Airbus knew and deliberately opted to ignore the very simple safety recommendation made after the second accident.
Well, I didn't "fail" to mention it mainly because it wasn't then and isn't now a problem endemic to Airbus and non-moving throttles - the very same thing, leaving a throttle open, has happened on Boeing aircraft.

Thrust levers/throttles on airplanes are, without exception, simple, mainly because they can be a single-point of failure if mis-handled. Push them forward, more power, pull them all the way back, power to idle. Airbus is absolutely no different than any other airplane.

Perhaps it is a momentary helmet fire or perhaps it is a lack of understanding of the a/thr system through lack of training, practise or momentary confusion.

This isn't an Airbus problem - it is a training/SOP matter. Second-guessing what is perceived as a "complex or different" system is not the pilots' perview or job - never has been. Millions and millions of hours have been flown on Airbus 320/340 series airplanes without a hitch. Same with Boeing. Non-moving thrust levers are not an issue for almost all crews but there will always be crews on both types which will have "issues". For me, the 767 throttles "hunting for speed" on approach drove me up a wall and I always disconnected them to stabilize the "wolf-and-rabbit" population phenomena of throttles chasing speed and vice-versa. When teaching on the 320, I always got my students to practise disconnecting and re-connecting the a/thr system so they had confidence in it and their ability to do so and understand.

What I, (and many, I suspect) am presently finding far more disconcerting is stories of avionics/software issues including spike detection and voting. Those are issues which may possibly be beyond a crew's ability to assess and successfully counter and this again isnt' only an Airbus issue.

PJ2
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Old 4th Dec 2008, 21:43
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ATS vs A-Throttle

For me, the 767 throttles "hunting for speed" on approach drove me up a wall and I always disconnected them to stabilize the "wolf-and-rabbit" population phenomena of throttles chasing speed and vice-versa.
Although I may understand your difficulty to "stabilize the wolf-and-rabbit population phenomena" I must tell you PJ2, that I never had to disconnect the Auto-Throttles on the A310 or B737 (except under moderate turbulence). When hand-flying, that "hunting for speed" momentum is normally reduced with good trimming technique. Unfortunately I can't say the same about all of the FBW aircraft I've flown: A320 family; A330 and A340...


When teaching on the 320, I always got my students to practise disconnecting and re-connecting the a/thr system so they had confidence in it and their ability to do so and understand.
So...they have to practice auto-thrust disconnection, hein? Did you have to "practice" auto-throttle "disconnection" on your 767, too? Or was it as easy as touching the instinctive disconnection push-button? Does this mean something about your aircraft? Or are we only "having issues" here too?
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Old 5th Dec 2008, 00:06
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aguadalte,

FBW airplanes are 4th generation airplanes and 737s, A310s and 767s are 3rd generation airplanes. One problem we pilots have (as with everyone) is being relunctant to accpet change. Aviation won`t return to the 3rd gen for sure, we are on our way to the 5th gen with so many stuff becoming available soon, like GPS technology, RNAV RNP, ADS-B, ethernet links allowing better use of automation, cockpit simplification, increased computer use and instead of 10 computers for 10 tasks, we`ll soon have 1 or 2 for 10 tasks.

My point is more and more things will be taken out of pilot control (at least for normal operations) and we just have to adapt and... enjoy. Automation will bring other problems for us to solve since automation is used to simplify what has been complicated (procedures, minima decrease, etc).

Again my point is, the A320 thrust levers are good, but not good enough as demonstrated by the incidents and accident that have happend. Airbus has disapointed me for not having come up with a better solution than an aural warning that was provided in a FWC upgrade that was not mandatory (that also involves local regulators, they also have some blame) at least inicially. I believe that after the Congonhas accident it is now mandatory, but I`m not sure. Airbus recognizes this since the A330 thrust levers design and from there on are different. So its a question of TL design and not the way they work. They are good!

If you would leave one TL on the 737 forward during landing the same result would happen, but the TL desing is different making it indeed more dificult to happen.

One other thing. You said you never disconnected the ATHR on the 737... I believe you, what you used to do was to override it. Why? Because it couldn`t keep speed... so it didn`t work well. For me an airplane that you have to override an automation most of the time, like the 737 ATHR - and I also flew it - its better for that airplane not to have that feature at all.

Returning to the original thread, looks like that nolonger 10 people will be charged. Charges against some 2 or 3 people will be withrawn because there was not enough matter.

Fly safe!
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Old 5th Dec 2008, 09:40
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My company is operating the Busses since the first day. As I didn´t like that design, I kept on flying the old fashioned designs. But I talked to hundreds of colleagues and friends during that 18 years, who were flying the bus. Guess what answer you get, if you ask them about the non-moving-throttle design (...and the non-feed-back sidestick design) ??
In 99,9 % they will tell you: You get used to it !! You can be satisfied now, but you don´t have to. Just ask the second question: Was it a good decision to design it like that, or would you prefer a moving-throttle and feed-backing sidestick ?
You can surely easily guess the answer.
And why didn´t Airbus react ? Obviously we have to face the fact, that our oppinion
is the most irrelevant in the business.
I remember the words of one of the first EADS Chairmans: the most expensive passenger seats are the two in the cockpit.
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Old 5th Dec 2008, 10:06
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ATS vs A-Throttle

TO MEMO,
Have you read all my contributions to this thread? I don't believe so, otherwise you wouldn't be paternalizing me with that story of being reluctant to accept change...that's the formal Airbus Industrie answer I've being hearing for almost two decades...
I fly Airbuses for more than 18 years. I (generally), like them. What I'm standing for is for moving throttles and side-stick feed-back! I know I'll never "win" this war. But do we have to accept it, just because "Change Happensnzzz"?

My company is operating the Busses since the first day. As I didn´t like that design, I kept on flying the old fashioned designs. But I talked to hundreds of colleagues and friends during that 18 years, who were flying the bus. Guess what answer you get, if you ask them about the non-moving-throttle design (...and the non-feed-back sidestick design) ??
In 99,9 % they will tell you: You get used to it !! You can be satisfied now, but you don´t have to. Just ask the second question: Was it a good decision to design it like that, or would you prefer a moving-throttle and feed-backing sidestick ?
You can surely easily guess the answer.
And why didn´t Airbus react ? Obviously we have to face the fact, that our oppinion
is the most irrelevant in the business.
I remember the words of one of the first EADS Chairmans: the most expensive passenger seats are the two in the cockpit.
Baron737,
Unfortunately my company is for a very long time an All Airbus Company, otherwise I would have done like you...
I do agree with your post, and, do you know why that EADS guy said that? Because most of us, are mere spectators in the cockpit! Accustomed spectators...
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Old 5th Dec 2008, 15:40
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They failed to publish at minimum an FCOM BULLETIN as subject : Landing with one deactivated Thrust Reverser
? Didn't understand. Simply pull BOTH levers to idle, then land.
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Old 5th Dec 2008, 18:10
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Say again ???

Aquadalte please explain what you meant by this sentence: “do you know why that EADS guy said that? Because most of us, are mere spectators in the cockpit! Accustomed spectators...”
We are about the same age and I assume you are a Captain on an Airbus. I have 13K hours of flight time; I suspect you have just as much or more. I’ve worked in this industry for nearly 30 years you have probably done the same. During that time I have served as a mechanic, dispatcher, First Officer, Captain and instructor pilot at the airline level; I believe your resume is just as rich or even more experienced. As an ex-airline instructor pilot, and current airline (737 Classic & NG) Captain I have had the opportunity to evaluate and train hundreds of pilots. My observation is that the overwhelming vast majority of who are consummate professionals dedicated to the highest level of competency and safety. That holds true whether I am talking about the pilots I have had the privilege of serving with flying the remote bush in Africa or the last first officer I flew with executing the most recent RNP RNAV approach technology available in mountainous terrain right down to minimums during a snow storm last week.
For every one of us convicted of operating an aircraft under the influence of alcohol there are tens of thousands who would never jeopardize safety in any way. As a group we shoulder tremendous amounts of responsibility that most of the rest of the world takes out liability insurance to mitigate the exposure and/or hides under layers of bureaucracy to shield themselves from. Virtually no other work group is as scrutinized as closely professional pilots commanding airliners are; everything you say is recorded virtually everything you do is logged by one or more sources. We think in 3 dimensions at 7 to 10 nautical miles a minute. We have a working knowledge of hardware/software/electronics, electricity, hydraulics and pneumatic systems. We are responsible for executing without error a vast array of frequently modified procedures under normal, abnormal, and emergency circumstances. Many of us, such as yourself, are proficient in several languages and use them under extremely technical circumstances during the course of our work. Because as a group we are so very good at what we do we make it look easy, that is a good definition of a consummate professional. You are so very good at what you do that you make it look easy. What we often do not do well as a group is to communicate the tremendous complexity and responsibility that in reality is our job. Because we often we fail to accurately communicate the real demands of our job those individuals who are detached by several layers from the left front seat can form an erroneous impression. How dare some “guy” insinuate that most of us are mere spectators – what a foolish statement (his not yours).
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Old 5th Dec 2008, 21:58
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My appologies, Northbeach, I may have expressed myself incorrectly.
I meant to say that we're often seen by the public as the "lucky guys who usually get all the girls, earn great salaries and go to work two or three times a month..."
The alleged EADS chairman phrase: "the most expensive passenger seats are the two in the cockpit" reflects that lack of respect for the "two guys in front", the industry seems to share. If he really said that, it means that they see us, as an expensive need, not as valuable assets. It would be totally different if the passenger word was taken out of the phrase.
And we really are "spectators", when we just accept what we get, without fighting for better human/machine interfaced equipment and when we just rest in this "we get used to it" way of handling this metters.

P.S.- I really don't understand some insensible positions like:
? Didn't understand. Simply pull BOTH levers to idle, then land.
This guys are either unexperienced or not humans, they never commited a mistake...
Errare humanum est
A.
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Old 5th Dec 2008, 22:10
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Thank you for the reply.

No apology needed, I suspected the error was on my part understanding what you were saying. I am in complete agreement. Well said!

Respectfully,

Northbeach
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Old 6th Dec 2008, 10:12
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Aguadalte,

My dear TAP friend!

Yes I read all your posts! And that`s why I decided to reply to you, because instead of discussing the original thread you`re trying to explain everyone that you don`t like the FBW, and yes... I agree with you there are some design erros in the AI concept! As also Boeing has some design erros in some of their aircraft, like the 737 rudder, etc...

Lets face it... automation will be more and more present in aviation and that will only oblige us to be more and more carefull, professional, dedicated, etc

The original thread was discussing something very important about criminal prossecution on people known to be envolved in one of the many factors that lead to the accident.

Did you read the link to "Folha de S Pauulo" that the safety officer pilot and responsible for the SMS of TAM is one of the ones going to court? That is completely wrong! You`re a pilot, like me, do you agree that the safety management department to be indicted?

Cheers!
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