Turkish airliner crashes at Schiphol
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Fuel starvation was not the case, this preliminary conclusion comes from the reading of FDR recordings. I do no more see the point as to why to take space with such wrong (not only unfounded) speculations on a Flight Deck Forum!
And that is for you RA!
Clearly, I got it too.
On the first pages of the thread, from what I could see of the condition of the fan blades, I thought Fuel Starvation could have been the case (modest angular velocity at the time of impact). But this was proved wrong.
Now, I would advise to keep on checking here (there are also telephone numbers, so I guess -- again -- that any of you who has the right credentials and qualifications, and is really interested, could get a strictly confidential anteprima):
Crashed during appraoch, Boeing 737-800, Amsterdam Airport Schiphol - De Onderzoeksraad voor veiligheid
Cheers to you, BOAC.
Paolo
And that is for you RA!
Clearly, I got it too.
On the first pages of the thread, from what I could see of the condition of the fan blades, I thought Fuel Starvation could have been the case (modest angular velocity at the time of impact). But this was proved wrong.
Now, I would advise to keep on checking here (there are also telephone numbers, so I guess -- again -- that any of you who has the right credentials and qualifications, and is really interested, could get a strictly confidential anteprima):
Crashed during appraoch, Boeing 737-800, Amsterdam Airport Schiphol - De Onderzoeksraad voor veiligheid
Cheers to you, BOAC.
Paolo
Last edited by vonbag; 28th Mar 2009 at 19:58.
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Nonetheless,a 'triangle of protection' can be identified - pilot performance (through screening at selection, knowledge, training, experience etc), company culture and aircraft capability. If all three are attacked then there is a way out of these types of accidents. I do accept that the A320 series is not perfect, but it is nonetheless a genuinely 'smart' machine which provides significant, but not foolproof, protections against pilot mishandling.
(the introduction of MPL is reducing actual flight hours in our ab initio training by another 30 % after it was already recuced by 50 % since the end of the 80īs in my company) No problem, because we have īsmartī machines ? The statistics show the opposite.
How can we avoid a loss of control accident ? Some more computers, or some more protection modes (...which of course will cause other accidents - f.e. Quantas 330). Or would it be smarter, to invest again in a pilot who can control pitch and power ?
On line training wouldnīt cost anything, btw.
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Am I missing something here, Boeing have published the probable cause and the recommendations to 737 operators over a week ago!
God help us if some of the contributors to these threads get anywhere near a real aircraft, other than as a passenger!
TECH Bulletin 737-09-2-R1
Ok, one could ask why no one was monitoring the thrust levers or speed decay, but that would be guesswork.
God help us if some of the contributors to these threads get anywhere near a real aircraft, other than as a passenger!
TECH Bulletin 737-09-2-R1
Ok, one could ask why no one was monitoring the thrust levers or speed decay, but that would be guesswork.
Per Ardua ad Astraeus
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Originally Posted by KG
Am I missing something here, Boeing have published the probable cause and the recommendations to 737 operators over a week ago!
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Here you go!
BOEING COMMERCIAL AIRPLANE GROUP
FLIGHT OPERATIONS TECHNICAL BULLETIN
NUMBER:
DATE:
737-09-2 R1
March 30, 2009
These bulletins provide information which may prove useful in airline operations or airline training. This
information will remain in effect depending on production changes, customer-originated modifications, and Service
Bulletin incorporation. Information in these bulletins is supplied by the Boeing Company and may not be approved
or endorsed by the FAA at the time of writing. Applicable documentation will be revised as necessary to reflect the
information contained in these bulletins. For further information, contact Boeing Commercial Airplane Group,
Chief Pilot, Flight Technical, P.O. Box 3707, Mail Stop 14-HA, Seattle, WA, USA 98124-2207, Phone (206) 5449610,
Fax (206) 544-9687, SITA: SEABO7X Station 627.
SUBJECT: Flight Crew Monitoring During Automatic Flight
ATA NO:
APPLIES TO: 737 All
Background Information
An erroneous Low Range Radio Altimeter (LRRA) has been identified in connection with
a recent 737-800 accident.
The Digital Flight Data Recorder (DFDR) data indicates that the crew was using both the
autopilot and the autothrottle during an ILS approach. The right LRRA was providing
accurate data to the first officers display and the left LRRA was erroneously providing a
reading of -8 feet to the captains display. No amber RA flag was displayed because the
left LRRA system did not declare the data invalid.
On all 737s, the autothrottle logic uses left radio altimeter data if the left radio altitude is
being displayed. This is regardless of the autopilot selected. On the 737NG, if the left
amber RA flag is displayed in place of radio altitude, the autothrottle will use right radio
altimeter data instead. On the 737-200 and 737-300/400/500, the autothrottle computer is
only connected to the left radio altimeter; therefore, if the left RA failure flag is displayed,
there will be no radio altimeter inputs to the autothrottle.
In this event, when the airplane descended through approximately 1950 feet on the
approach with flaps extended beyond 12 ― degrees, the autothrottle erroneously sensed
that the airplane was in landing flare. The thrust levers were retarded to the idle stop
where they remained for approximately 100 seconds. For the first 70 of the 100 seconds,
idle thrust was sufficient to maintain the selected airspeed. During the next 30 seconds,
Page 1 of 4
airspeed decreased below the selected MCP speed to approximately 40 knots below the
selected approach speed.
The two LRRA systems provide height above ground data to aircraft systems which
include the displays, autothrottle, autopilots and configuration/ground proximity warning.
If one LRRA provides erroneous altitude readings, the associated flight deck effects may
typically include:
Large differences between displayed radio altitude.
Inability to engage both autopilots in dual channel approach (APP) mode.
Unexpected removal of the Flight Director Command Bars during approach on
the pilots side with the erroneous radio altimeter display.
Unexpected Configuration Warnings after takeoff, during approach, or during go-
around.
Inappropriate Flight Mode Annunciation (FMA) indication of autothrottle
RETARD mode during approach phase with the airplane above 27 feet AGL.
There will also be corresponding thrust lever movement towards the idle stop.
The FMA will continue to indicate RETARD after the thrust levers have reached
the idle stop rather than change to ARM.
Boeing Recommendations
Whether in automated or manual flight, flight crews must carefully monitor primary
flight instruments (airspeed, attitude etc.) for aircraft performance and the FMA for
autoflight modes.
The following information is taken from the Flight Crew Training Manual (FCTM) and
has been adapted to provide Flight Crews and Operators with guidelines which should be
followed if a flight crew encounters any of the above mentioned indications.
General Guidelines
Condition:
Large differences between displayed data.
Crew Resource Management (CRM) involves the effective use of all available resources
to operate a flight safely. It is important that all flight deck crewmembers identify and
communicate any situation that appears potentially unsafe or out of the ordinary.
Experience has proven that the most effective way to maintain safety of flight and resolve
these situations is to combine the skills and experience of all crewmembers in the
decision making process to determine the safest course of action.
Situational awareness, or the ability to accurately perceive what is going on in the flight
deck, requires ongoing questioning, crosschecking, communication, and refinement of
perception.
Page 2 of 4
Condition:
Inability to engage both autopilots in dual channel approach (APP) mode.
Unexpected removal of the Flight Director Command Bars during approach on
the pilots side with the erroneous radio altimeter display.
Inappropriate Flight Mode Annunciation (FMA) indication of autothrottle
RETARD mode during approach phase with the airplane above 27 feet AGL.
There will also be corresponding thrust lever movement towards the idle stop.
The FMA will continue to indicate RETARD after the thrust levers have reached
the idle stop rather than change to ARM.
Automatic systems give excellent results in the vast majority of situations. Faults can
occur at any point during an automatic approach. Many non-normal situations or
scenarios are possible. The flight deck is designed so that a quick analysis and decision
can be made for virtually all non-normal or fault situations using the autopilot/autothrottle
indicators, FMAs, master caution system and, for fail operational airplanes, autoland
status annunciations. Deviations in intended flight path or unexpected thrust lever
movement may also be an indication of an automation fault.
If the flight crew is aware of a degraded Autopilot Flight Director Systems (AFDS) mode,
special recognition should be given during the Approach Briefing as to how to manage the
use of the automatic features.
Note:
Early intervention prevents unsatisfactory airplane performance or a
degraded flight path.
When the automatic systems as described above do not perform as expected, the PF
should reduce the level of automation to ensure proper control of the airplane is
maintained.
The PF should not attempt to restore higher levels of automation until after aircraft
control is assured.
Condition:
Unexpected Configuration Warnings after takeoff, during approach, or during
go-around.
Flight crew must ensure the proper configuration for the phase of flight. Time may be
required in order to assess the situation, take corrective action and resolve the
discrepancy; therefore a go-around, holding, or additional maneuvering may be
necessary. Flight path control and monitoring of instruments must never be
compromised.
Page 3 of 4
Non-Normal Situation Guidelines
When a non-normal situation occurs, the following guidelines apply.
NON-NORMAL RECOGNITION:
o
The crewmember recognizing the malfunction calls it out clearly and
precisely.
MAINTAIN AIRPLANE CONTROL:
o
It is mandatory that the Pilot Flying (PF) fly the airplane.
ANALYZE THE SITUATION:
o
Any further action should only be initiated after the malfunctioning
system has been positively identified.
Additional Information
Any occurrences of erroneous display data, even if intermittent, should be reported to
maintenance.
More information can be found in the Boeing 737 Flight Crew Training Manual and
Flight Crew Operations Manual. Operators may want to review the following:
737 FCTM
1. Chapter 1 - Crew Resource Management
2. Chapter 1 - Callouts
3. Chapter 1 - AFDS Guidelines
4. Chapter 5 - Approach Briefing
5. Chapter 5 - Stabilized Approach Recommendations
737 FCOM
1. NP11 - Autopilot Flight Director Systems (AFDS) Procedures
2. Chapter 4 - Automatic Flight System Description
3. Chapter 10 - Flight Instruments, Displays System Description
4. Chapter 15 -Warning Systems System Description
Page 4 of 4
BOEING COMMERCIAL AIRPLANE GROUP
FLIGHT OPERATIONS TECHNICAL BULLETIN
NUMBER:
DATE:
737-09-2 R1
March 30, 2009
These bulletins provide information which may prove useful in airline operations or airline training. This
information will remain in effect depending on production changes, customer-originated modifications, and Service
Bulletin incorporation. Information in these bulletins is supplied by the Boeing Company and may not be approved
or endorsed by the FAA at the time of writing. Applicable documentation will be revised as necessary to reflect the
information contained in these bulletins. For further information, contact Boeing Commercial Airplane Group,
Chief Pilot, Flight Technical, P.O. Box 3707, Mail Stop 14-HA, Seattle, WA, USA 98124-2207, Phone (206) 5449610,
Fax (206) 544-9687, SITA: SEABO7X Station 627.
SUBJECT: Flight Crew Monitoring During Automatic Flight
ATA NO:
APPLIES TO: 737 All
Background Information
An erroneous Low Range Radio Altimeter (LRRA) has been identified in connection with
a recent 737-800 accident.
The Digital Flight Data Recorder (DFDR) data indicates that the crew was using both the
autopilot and the autothrottle during an ILS approach. The right LRRA was providing
accurate data to the first officers display and the left LRRA was erroneously providing a
reading of -8 feet to the captains display. No amber RA flag was displayed because the
left LRRA system did not declare the data invalid.
On all 737s, the autothrottle logic uses left radio altimeter data if the left radio altitude is
being displayed. This is regardless of the autopilot selected. On the 737NG, if the left
amber RA flag is displayed in place of radio altitude, the autothrottle will use right radio
altimeter data instead. On the 737-200 and 737-300/400/500, the autothrottle computer is
only connected to the left radio altimeter; therefore, if the left RA failure flag is displayed,
there will be no radio altimeter inputs to the autothrottle.
In this event, when the airplane descended through approximately 1950 feet on the
approach with flaps extended beyond 12 ― degrees, the autothrottle erroneously sensed
that the airplane was in landing flare. The thrust levers were retarded to the idle stop
where they remained for approximately 100 seconds. For the first 70 of the 100 seconds,
idle thrust was sufficient to maintain the selected airspeed. During the next 30 seconds,
Page 1 of 4
airspeed decreased below the selected MCP speed to approximately 40 knots below the
selected approach speed.
The two LRRA systems provide height above ground data to aircraft systems which
include the displays, autothrottle, autopilots and configuration/ground proximity warning.
If one LRRA provides erroneous altitude readings, the associated flight deck effects may
typically include:
Large differences between displayed radio altitude.
Inability to engage both autopilots in dual channel approach (APP) mode.
Unexpected removal of the Flight Director Command Bars during approach on
the pilots side with the erroneous radio altimeter display.
Unexpected Configuration Warnings after takeoff, during approach, or during go-
around.
Inappropriate Flight Mode Annunciation (FMA) indication of autothrottle
RETARD mode during approach phase with the airplane above 27 feet AGL.
There will also be corresponding thrust lever movement towards the idle stop.
The FMA will continue to indicate RETARD after the thrust levers have reached
the idle stop rather than change to ARM.
Boeing Recommendations
Whether in automated or manual flight, flight crews must carefully monitor primary
flight instruments (airspeed, attitude etc.) for aircraft performance and the FMA for
autoflight modes.
The following information is taken from the Flight Crew Training Manual (FCTM) and
has been adapted to provide Flight Crews and Operators with guidelines which should be
followed if a flight crew encounters any of the above mentioned indications.
General Guidelines
Condition:
Large differences between displayed data.
Crew Resource Management (CRM) involves the effective use of all available resources
to operate a flight safely. It is important that all flight deck crewmembers identify and
communicate any situation that appears potentially unsafe or out of the ordinary.
Experience has proven that the most effective way to maintain safety of flight and resolve
these situations is to combine the skills and experience of all crewmembers in the
decision making process to determine the safest course of action.
Situational awareness, or the ability to accurately perceive what is going on in the flight
deck, requires ongoing questioning, crosschecking, communication, and refinement of
perception.
Page 2 of 4
Condition:
Inability to engage both autopilots in dual channel approach (APP) mode.
Unexpected removal of the Flight Director Command Bars during approach on
the pilots side with the erroneous radio altimeter display.
Inappropriate Flight Mode Annunciation (FMA) indication of autothrottle
RETARD mode during approach phase with the airplane above 27 feet AGL.
There will also be corresponding thrust lever movement towards the idle stop.
The FMA will continue to indicate RETARD after the thrust levers have reached
the idle stop rather than change to ARM.
Automatic systems give excellent results in the vast majority of situations. Faults can
occur at any point during an automatic approach. Many non-normal situations or
scenarios are possible. The flight deck is designed so that a quick analysis and decision
can be made for virtually all non-normal or fault situations using the autopilot/autothrottle
indicators, FMAs, master caution system and, for fail operational airplanes, autoland
status annunciations. Deviations in intended flight path or unexpected thrust lever
movement may also be an indication of an automation fault.
If the flight crew is aware of a degraded Autopilot Flight Director Systems (AFDS) mode,
special recognition should be given during the Approach Briefing as to how to manage the
use of the automatic features.
Note:
Early intervention prevents unsatisfactory airplane performance or a
degraded flight path.
When the automatic systems as described above do not perform as expected, the PF
should reduce the level of automation to ensure proper control of the airplane is
maintained.
The PF should not attempt to restore higher levels of automation until after aircraft
control is assured.
Condition:
Unexpected Configuration Warnings after takeoff, during approach, or during
go-around.
Flight crew must ensure the proper configuration for the phase of flight. Time may be
required in order to assess the situation, take corrective action and resolve the
discrepancy; therefore a go-around, holding, or additional maneuvering may be
necessary. Flight path control and monitoring of instruments must never be
compromised.
Page 3 of 4
Non-Normal Situation Guidelines
When a non-normal situation occurs, the following guidelines apply.
NON-NORMAL RECOGNITION:
o
The crewmember recognizing the malfunction calls it out clearly and
precisely.
MAINTAIN AIRPLANE CONTROL:
o
It is mandatory that the Pilot Flying (PF) fly the airplane.
ANALYZE THE SITUATION:
o
Any further action should only be initiated after the malfunctioning
system has been positively identified.
Additional Information
Any occurrences of erroneous display data, even if intermittent, should be reported to
maintenance.
More information can be found in the Boeing 737 Flight Crew Training Manual and
Flight Crew Operations Manual. Operators may want to review the following:
737 FCTM
1. Chapter 1 - Crew Resource Management
2. Chapter 1 - Callouts
3. Chapter 1 - AFDS Guidelines
4. Chapter 5 - Approach Briefing
5. Chapter 5 - Stabilized Approach Recommendations
737 FCOM
1. NP11 - Autopilot Flight Director Systems (AFDS) Procedures
2. Chapter 4 - Automatic Flight System Description
3. Chapter 10 - Flight Instruments, Displays System Description
4. Chapter 15 -Warning Systems System Description
Page 4 of 4
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So the main point of Boeing's report is: Pilots must monitor their screens. But surely this is so horribly basic, its like saying a car might crash unless the driver looks where they are going?
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So the main point of Boeing's report is: Pilots must monitor their screens. But surely this is so horribly basic, its like saying a car might crash unless the driver looks where they are going?
from the report:
Owww....shocking.
also:
This could be a nice one. if Turkish airlines is accustomed to leave the A/P on in all circumstances, how are they going to deal with this Boeing statement?
It is mandatory that the Pilot Flying (PF) fly the airplane.
also:
When the automatic systems as described above do not perform as expected, the PF
should reduce the level of automation to ensure proper control of the airplane is
maintained.
should reduce the level of automation to ensure proper control of the airplane is
maintained.
This could be a nice one. if Turkish airlines is accustomed to leave the A/P on in all circumstances, how are they going to deal with this Boeing statement?
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"pilots are there to push buttons...... and the automatics doing everything else."
Berganair B757 out of the Caribbean. ADC LHS failed on takeoff below 80kts. Capt decided to continue and trouble shoot in the air. F/O PF and all on RHS was OK. Engaged C autopilot as standard. It was connected to L ADC. Oops. A/c stalled under command of the automatics and a/c performed barrel roll into the sea. The automatics sure as hell did everything else on that day. Oh dear! Once again a 99% serviceable a/c crashed, all died due to lack of PF flying the a/c, analise the problem and then the unusual scenario can be diagnosed before attaching the flying a/c to the automatics which were not behaving normally. Of course it would have been better to abort the takeoff and discuss it in the bar.
Often the automatics can reduce the workload/stress and allow a relaxed analysis, but the need to be used with care, certainty and monitored constantly in these circumstances. Shades of the L1011 down in the Everglades as well. The circle keeps turning.
Berganair B757 out of the Caribbean. ADC LHS failed on takeoff below 80kts. Capt decided to continue and trouble shoot in the air. F/O PF and all on RHS was OK. Engaged C autopilot as standard. It was connected to L ADC. Oops. A/c stalled under command of the automatics and a/c performed barrel roll into the sea. The automatics sure as hell did everything else on that day. Oh dear! Once again a 99% serviceable a/c crashed, all died due to lack of PF flying the a/c, analise the problem and then the unusual scenario can be diagnosed before attaching the flying a/c to the automatics which were not behaving normally. Of course it would have been better to abort the takeoff and discuss it in the bar.
Often the automatics can reduce the workload/stress and allow a relaxed analysis, but the need to be used with care, certainty and monitored constantly in these circumstances. Shades of the L1011 down in the Everglades as well. The circle keeps turning.
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llondel is just showing his British sense of humor.
Reminds me of the oil guy that came to the US, bought a $300,000 motorhome, got on the turnpike, put it on cruise control went to the back to get a drink and crashed. He sued because the manual didn't say cruise control only controlled speed.
Reminds me of the oil guy that came to the US, bought a $300,000 motorhome, got on the turnpike, put it on cruise control went to the back to get a drink and crashed. He sued because the manual didn't say cruise control only controlled speed.
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There was a leakage path in the radio altimeter antenna system that caused the -8 feet indication. At some point on the approach, valid ground return would have been enough to overcome the signal strength of the leakage path. That's why erroneous radio altimeter indications don't show up at the gate, and require more than "black box swapper" skill to troubleshoot.
Did the #1 radalt start working correctly again at, say 1000 feet? If so, would the A/T have cancelled the Retard indication, or was it latched into a Retard logic routine? If the A/T logic had reset, the A/T would not have left the throttles at idle.
GB
Did the #1 radalt start working correctly again at, say 1000 feet? If so, would the A/T have cancelled the Retard indication, or was it latched into a Retard logic routine? If the A/T logic had reset, the A/T would not have left the throttles at idle.
GB
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There was a leakage path in the radio altimeter antenna system that caused the -8 feet indication. At some point on the approach, valid ground return would have been enough to overcome the signal strength of the leakage path. That's why erroneous radio altimeter indications don't show up at the gate, and require more than "black box swapper" skill to troubleshoot.
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Per Ardua ad Astraeus
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Many thanks, KG:
- I have to take you back a step, as you are assuming that
- took place. As fox niner points out, "It is mandatory that the Pilot Flying (PF) fly the airplane." and, of course, that the other pilot monitors, and even more importantly, in a training environment, that the TC is on the ball.
I note no comment there about the attempted recovery from stick shake. That surprises me, unless of course our info so far is incorrect.
Originally Posted by TP
You are wrong. This is the main point:
NON-NORMAL RECOGNITION:
I note no comment there about the attempted recovery from stick shake. That surprises me, unless of course our info so far is incorrect.
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NON-NORMAL RECOGNITION
What was the 'non-normal?
RA information was irrelevant to their approach and it seems likely (and even understandable) that the captain did not notice it was reading -8ft. Remember that there was probably no fault warning. Even if he had noticed it is possible he did not mentally connect that with any effect on the A/T as this involved fairly esoteric system knowledge.
The non-normal was therefore the inappropriate enunciation of RETARD and the failure of the A/T to apply power when required.
Just thought I would clarify that.
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BOAC
I think we agree
Retard + no A/T response + no crew reaction = Vref - 40
What I was trying to clarify was that the RA fault was not the decisive 'non-normal' before we get more endless discussion about the RA system.
I think we agree
Retard + no A/T response + no crew reaction = Vref - 40
What I was trying to clarify was that the RA fault was not the decisive 'non-normal' before we get more endless discussion about the RA system.
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763 Jock, what to say , really , nothing to add.
What does it say on your contract " Pilot" ?
Basic description of job ? keep large chunk of aluminium containing human life in air from A to B.
Feel free to use any bits of technology found in aforesaid bit of aluminium, but don't forget that YOU are employed to point aforesaid vessel in good direction at all times.
I think Boeing are showing WAY WAY beyond the level of political correctness I would employ ( no doubt with a legal stance in mind)
YOU are employed as a PILOT, do you mind ( PLEASE) to perform the function we requested (BASIC ONE) if you wish to collect a salary at the end of the month ?
End of message.
DUH. . . . What is the job ?
Uh? . . . . I am a pilot
Mmmn, what does that involve ?
Duh
Well, Ermn ' Well. Well I think it involves taking that chunk of aluminium from A to B without hitting anything on the way, is that OK ?
What does it say on your contract " Pilot" ?
Basic description of job ? keep large chunk of aluminium containing human life in air from A to B.
Feel free to use any bits of technology found in aforesaid bit of aluminium, but don't forget that YOU are employed to point aforesaid vessel in good direction at all times.
I think Boeing are showing WAY WAY beyond the level of political correctness I would employ ( no doubt with a legal stance in mind)
YOU are employed as a PILOT, do you mind ( PLEASE) to perform the function we requested (BASIC ONE) if you wish to collect a salary at the end of the month ?
End of message.
DUH. . . . What is the job ?
Uh? . . . . I am a pilot
Mmmn, what does that involve ?
Duh Well, Ermn ' Well.
Well I think it involves taking that chunk of aluminium from A to B without hitting anything on the way, is that OK ?
Last edited by captplaystation; 8th Apr 2009 at 23:36.