Turkish airliner crashes at Schiphol
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RAT 5 :
No lack of that on this forum.
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.
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Asleep at the wheel
How asleep do you have to be to get all the way to Vref-40 on finals? I appreciate the workload is high, but seriously, all the clues are there, right?
BHDH.
BHDH.
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Glass houses/ stones and all that, but . . . . well, Yep, difficult to justify.
I think EVERYONE who flies any aircraft for a living, is waiting to hear some one come up with an explanation of how they ended up so far out of the ballpark
I think EVERYONE who flies any aircraft for a living, is waiting to hear some one come up with an explanation of how they ended up so far out of the ballpark
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What time was it after us old guys retired did procedures not require someone to be monitoring the automation? I never trusted an autoland approach enough to take my hands off of the controls and disconnected at the first indication of deviance from what was desired. Have the new procedures changed? The manufacturer should not be held responsible for this accident because the #1 RA wasn't working properly. Two people were asleep at the wheel.
Re “…monitoring the automation…” (#2225)
Part of the problem is that current teaching involves monitoring automation, whereas monitoring the aircraft flight path as if it were being hand flown by another pilot should provide a clearer understanding of the situation.
It is necessary to check FMA, RA displays etc, but in sensible priority to the larger picture of what the aircraft is doing;- attitude, airspeed, altitude, hdg/trk – a robust basic instrument scan.
With time available, where the scan includes subsidiary items, it may be possible to project deviations or failure from faults (thinking ahead), but with time constraint – high workload, training demand, inexperience, then we have to rely on a basic scan pattern to detect aircraft deviation from prescribed limits. If automation is the cause, correct or disconnect it. If evaluation time is short, don’t let the situation determine the future – you do that, intervene in the situation with manual flight.
Part of the problem is that current teaching involves monitoring automation, whereas monitoring the aircraft flight path as if it were being hand flown by another pilot should provide a clearer understanding of the situation.
It is necessary to check FMA, RA displays etc, but in sensible priority to the larger picture of what the aircraft is doing;- attitude, airspeed, altitude, hdg/trk – a robust basic instrument scan.
With time available, where the scan includes subsidiary items, it may be possible to project deviations or failure from faults (thinking ahead), but with time constraint – high workload, training demand, inexperience, then we have to rely on a basic scan pattern to detect aircraft deviation from prescribed limits. If automation is the cause, correct or disconnect it. If evaluation time is short, don’t let the situation determine the future – you do that, intervene in the situation with manual flight.
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Stop speculating, please!
"There is no blame to the automatic system, this accident is down to a deep, deep failing of the human factors element- that is where the serious failure lay. We rely on human situational awareness to keep us alive- the way that failed here is of despair to all pilots." - Rainboe
Yes, maybe if we blame and criminalise pilots we can begin to do someting meaningful about safety! really? And what actually is situational awareness? People throw that term around so much it looses all meaning, peoples interpretation of it becomes so subjective. You are so caught with the view of hindsight and you fail to consider how the situation may have unfolded from the perspective of the crew, at that time, in their environment, what were they aware of? It is too early to tell, so why speculate further? The HF experts have only just begun to look into all the factors, trying to paste all the messey details together.
But carry on ranting, go ahead, maybe if we scare enough pilots they will stop making UNINTENTIONAL mistakes. How will this encourage a fair / just culture or open reporting system? If you carry on voicing these views,we will all very soon all end up in a smoking hole in the ground.
Yes, maybe if we blame and criminalise pilots we can begin to do someting meaningful about safety! really? And what actually is situational awareness? People throw that term around so much it looses all meaning, peoples interpretation of it becomes so subjective. You are so caught with the view of hindsight and you fail to consider how the situation may have unfolded from the perspective of the crew, at that time, in their environment, what were they aware of? It is too early to tell, so why speculate further? The HF experts have only just begun to look into all the factors, trying to paste all the messey details together.
But carry on ranting, go ahead, maybe if we scare enough pilots they will stop making UNINTENTIONAL mistakes. How will this encourage a fair / just culture or open reporting system? If you carry on voicing these views,we will all very soon all end up in a smoking hole in the ground.
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Maybe I will repeat something already said in this forum, but I am sure that few months ago the turkish crew was discussing the supposed mistakes (if any)of the Airbus Perpignan accident in the same way we are discussing the supposed mistakes (if any) of the Schipol accident : probably the Turkish crew were talking, between themselves, about the lack of this/that, poor airmanship, aircraft technology, and so on…
But I am sure , as most of you will be, that they were not a suicidal crew (and the Perpignan crew as well..).All the above just to say that this type of accident can happen to everybody . Am I saying the obvious? Yes, maybe. But the acrimony I see sometimes on this forum reminds me about , for example, what we say/think when we see a car crash on the motorway and we are happy not only not to be the victim, but how smart we have been up to now to survive with our superior driving abilities--- until we incur in those semi-fatal three-seconds distractions (we too, yes ! ) which quite caused us to be killed us in a similar car incident...!
But I am sure , as most of you will be, that they were not a suicidal crew (and the Perpignan crew as well..).All the above just to say that this type of accident can happen to everybody . Am I saying the obvious? Yes, maybe. But the acrimony I see sometimes on this forum reminds me about , for example, what we say/think when we see a car crash on the motorway and we are happy not only not to be the victim, but how smart we have been up to now to survive with our superior driving abilities--- until we incur in those semi-fatal three-seconds distractions (we too, yes ! ) which quite caused us to be killed us in a similar car incident...!
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But carry on ranting, go ahead, maybe if we scare enough pilots they will stop making UNINTENTIONAL mistakes.
...we incur in those semi-fatal three-seconds distractions...
But we are talking about a team of three drivers - all seemingly distracted for one hundred seconds - and no mitigating reason has yet been officially proposed.
Case closed? Of course not. But the official silence is disquieting.
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Rainboe:
I agree with most of what you said.
But my opinion Is that nobody will do such mistakes intentionally, not a 14.000+ Captain, nor a 70.000-combined crew involved in a maintenance check flight, but they happened. Incompetence ? Maybe, but those accident happened unintentionally ! Accidents happen also to truck drivers and bus drivers (professional drivers), and also in that case they should not happen, and this is what a bus passengers expect from them : to safely arrive at the destination. Survived professional driver/pilots will probably undergo a trial, and I agree with that, if they are at fault , they deserve punishment, as everybody else. But my point is that for most of those accident neglicence (culpable neglicence ? negligence ‘in vigilando’, a lawyer would say ? ) probably is the main reason, and I agree with you that this type of mistake should not be made by professionals – whichever type of professional.
I agree with most of what you said.
But my opinion Is that nobody will do such mistakes intentionally, not a 14.000+ Captain, nor a 70.000-combined crew involved in a maintenance check flight, but they happened. Incompetence ? Maybe, but those accident happened unintentionally ! Accidents happen also to truck drivers and bus drivers (professional drivers), and also in that case they should not happen, and this is what a bus passengers expect from them : to safely arrive at the destination. Survived professional driver/pilots will probably undergo a trial, and I agree with that, if they are at fault , they deserve punishment, as everybody else. But my point is that for most of those accident neglicence (culpable neglicence ? negligence ‘in vigilando’, a lawyer would say ? ) probably is the main reason, and I agree with you that this type of mistake should not be made by professionals – whichever type of professional.
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This accident has done more to destroy human piloting in the future than any of us realise. The designers are busy designing us out of the system now!
Then, if human intervention or (non) intervention is not done from the cockpit, it will be done somehow somewhere from the ground ...
Much better to have someone at the front who does anything to save its own life than someone on the ground ...
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A few post back I gave a fairly accurate descrition of the accident sequence.
I too do not believe the automatics can be blamed. We train on a regular basis for the most horrible scenarios, engine fires/failures etc. It can not be that a simple failure(I know it didn't fail but it wasn't working correctly) of the RA could lead to an accident.
However I do try to learn from it, could I have made the same mistake?
Once again, the only thing wrong for the first 70 seconds was the RETARD annunciation instead of MCP speed, other than that the airplane was behaving exactly as it was supposed to. How many guys would have caught that? And, once again the FO might even have noticed but didn't realise it was not appropiate for that stage of flight. I have once descended in VNAV wondering why the A/C was not following the profile, only later to realise the A/C was descending in VNAV SPD instead of VNAV PATH.
It's gonna be interesting when the final report comes out and a transcript of the CVR is released if the FP or the PM said "retard" and the other pilot said "checked". I'm gonna go out on a limb and expose myself to the ridicule of the pilots on here, but I in that stage of my training I possibly could have not realised RETARD was not appropriate for that stage of flight.
The speed decay from FAS to stick shaker is beyond me, really!
But the recovery, the P/L's going back to idle, hmmm, however it won't happen to me now!
In the end, it's gonna be pilot error though, no doubt, but why??
I too do not believe the automatics can be blamed. We train on a regular basis for the most horrible scenarios, engine fires/failures etc. It can not be that a simple failure(I know it didn't fail but it wasn't working correctly) of the RA could lead to an accident.
However I do try to learn from it, could I have made the same mistake?
Once again, the only thing wrong for the first 70 seconds was the RETARD annunciation instead of MCP speed, other than that the airplane was behaving exactly as it was supposed to. How many guys would have caught that? And, once again the FO might even have noticed but didn't realise it was not appropiate for that stage of flight. I have once descended in VNAV wondering why the A/C was not following the profile, only later to realise the A/C was descending in VNAV SPD instead of VNAV PATH.
It's gonna be interesting when the final report comes out and a transcript of the CVR is released if the FP or the PM said "retard" and the other pilot said "checked". I'm gonna go out on a limb and expose myself to the ridicule of the pilots on here, but I in that stage of my training I possibly could have not realised RETARD was not appropriate for that stage of flight.
The speed decay from FAS to stick shaker is beyond me, really!
But the recovery, the P/L's going back to idle, hmmm, however it won't happen to me now!
In the end, it's gonna be pilot error though, no doubt, but why??
Last edited by flyburg; 9th Apr 2009 at 14:43.
But we are talking about a team of three drivers - all seemingly distracted for one hundred seconds - and no mitigating reason has yet been officially proposed.
Case closed? Of course not. But the official silence is disquieting.
Case closed? Of course not. But the official silence is disquieting.
I believe that safety is still being served.
The only weakness is that those who want to believe that "it can't happen to me"
Per Ardua ad Astraeus
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I have not read Learmount's article, but I still believe that we should rather be designing pilots INTO the system. Automation is a wonderful thing, and as some of us know, means we can nod off on along sector leaving 't'other to monitor the 'perfect' systems
However, I have never been so 'in the loop' as I was at 250'/420kts with a map in my hand or navigating an ageing 737-200 across the Atlantic to the Canaries on DR. Nowadays, we sail across the world with little thought as to how.
I have constantly argued for LESS automation and making the pilots do more. Yes, I love the modern FMS/GPS/magenta line stuff, but I know that lots of modern youngsters do not have a clue where they are and where they are actually going a lot of the time - indeed why should they? Why should they worry about speed when the aircraft will look after it for them? Why worry about stall recovery because the aircraft will NOT let you stall?
I firmly maintain that with the current state of the art in avionics, software writing skills and equipment we are going the wrong way in both design and training, and Schipol and Perpignan sadly re-inforce that view.
However, I have never been so 'in the loop' as I was at 250'/420kts with a map in my hand or navigating an ageing 737-200 across the Atlantic to the Canaries on DR. Nowadays, we sail across the world with little thought as to how.
I have constantly argued for LESS automation and making the pilots do more. Yes, I love the modern FMS/GPS/magenta line stuff, but I know that lots of modern youngsters do not have a clue where they are and where they are actually going a lot of the time - indeed why should they? Why should they worry about speed when the aircraft will look after it for them? Why worry about stall recovery because the aircraft will NOT let you stall?
I firmly maintain that with the current state of the art in avionics, software writing skills and equipment we are going the wrong way in both design and training, and Schipol and Perpignan sadly re-inforce that view.
NO - the NON-NORMAL was a speed 40kts below Vref which in my book is a bit unusual in the air
Rainboe, I agree with you too - whichever way you dress it up, your comments highlight the real cause.
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No excuse for stalling an airworthy airplane on final approach . . .
The operating CVR will explain the crew's distraction from monitoring the instruments and from staying focused during the final approach in day VMC.
This shocking, elementary breakdown in cockpit discipline during a critical phase of flight suggests that Türk Hava Yolları has to revamp its training program, with emphasis on strict adherence to SOPs.
This shocking, elementary breakdown in cockpit discipline during a critical phase of flight suggests that Türk Hava Yolları has to revamp its training program, with emphasis on strict adherence to SOPs.
Rainboe;
And Egyptair 990...
Your remarks are appropriately blunt and spot on the mark.
I am firmly in the camp of using a systems approach to flight safety where organizational factors are often ignored as first causes because these days that is an appropriate area of investigation given that human factors is by far the #1 cause of accidents. But at some point it has to be acknowledged that there is no other reasonable explanation for this accident than the captain, and the crew, did not do their job, and instead stalled their aircraft resulting in the deaths of passengers. There is simply no excuse available to an experienced professional crew for ignoring a 40kt reduction in airspeed for over a minute and fourty seconds on final. And I agree too, that Boeing has soft-pedaled this far too much. Why many are still dancing instead of looking at this for what it is, is disturbing for the very reason they give for dancing - "perhaps there is something deeper to learn here?" There is, and the sooner it is acknowledged the better: Why did the captain, and the two other pilots stall their aircraft?, and I am not pointing back to anything other than SA - what permitted the loss/absence of SA? Certainly not a radio altimeter fault, nor the warnings which resulted from same. The only possibility is a non-sterile cockpit environment, (which is also the subject of interest in the Colgan accident). The loss of SA is precisely where the lesson can be learned, if there are any lessons here at all. Again Rainboe - well focussed, well stated.
the Egypt Sharm 737
Your remarks are appropriately blunt and spot on the mark.
I am firmly in the camp of using a systems approach to flight safety where organizational factors are often ignored as first causes because these days that is an appropriate area of investigation given that human factors is by far the #1 cause of accidents. But at some point it has to be acknowledged that there is no other reasonable explanation for this accident than the captain, and the crew, did not do their job, and instead stalled their aircraft resulting in the deaths of passengers. There is simply no excuse available to an experienced professional crew for ignoring a 40kt reduction in airspeed for over a minute and fourty seconds on final. And I agree too, that Boeing has soft-pedaled this far too much. Why many are still dancing instead of looking at this for what it is, is disturbing for the very reason they give for dancing - "perhaps there is something deeper to learn here?" There is, and the sooner it is acknowledged the better: Why did the captain, and the two other pilots stall their aircraft?, and I am not pointing back to anything other than SA - what permitted the loss/absence of SA? Certainly not a radio altimeter fault, nor the warnings which resulted from same. The only possibility is a non-sterile cockpit environment, (which is also the subject of interest in the Colgan accident). The loss of SA is precisely where the lesson can be learned, if there are any lessons here at all. Again Rainboe - well focussed, well stated.
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Well thanks but I pretty much disagree with most of your points.
1,2,3 and 3
Once they intercepted the GS the airplsne would start to reduce speed as one would normally do. In line operations you use a decelerating rating type of approach. the pl's would go to the idle detent, the speed would start to reduce and the angle of attack would increase. The engine parameters would also indicate the engines being at idle.
read the boeing publication. It took about 70 seconds to decelerate to FAS, during this time the pl would have been at idle just as they would have been during a normal approach. It was the next 30 seconds where things went wrong. that's were the 40 kts speed reduction below FAS happened(still inexcusable) as the previous poster claimes, makes it more dramatic though,I agree.
I'm done with this thread. It is starting to get to the point were people feel the need to post just simple oneliners to prove how good they are. Great, I don't have a need to prove anything here though. Some interesting things where to be learned but not anymore.
good luck with the discussion.
p.s. reluctantly I'm going to agree with rainboe, a lot of people seem to have a reading disorder.
1,2,3 and 3
Once they intercepted the GS the airplsne would start to reduce speed as one would normally do. In line operations you use a decelerating rating type of approach. the pl's would go to the idle detent, the speed would start to reduce and the angle of attack would increase. The engine parameters would also indicate the engines being at idle.
read the boeing publication. It took about 70 seconds to decelerate to FAS, during this time the pl would have been at idle just as they would have been during a normal approach. It was the next 30 seconds where things went wrong. that's were the 40 kts speed reduction below FAS happened(still inexcusable) as the previous poster claimes, makes it more dramatic though,I agree.
I'm done with this thread. It is starting to get to the point were people feel the need to post just simple oneliners to prove how good they are. Great, I don't have a need to prove anything here though. Some interesting things where to be learned but not anymore.
good luck with the discussion.
p.s. reluctantly I'm going to agree with rainboe, a lot of people seem to have a reading disorder.
Last edited by flyburg; 9th Apr 2009 at 17:59.
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Rainboe in response to your post about Turkey.
They are proud people, of their country and culture, it is also well know to be very corrupt when it comes to anything such as this, money talks, if it goes into the pockets of the politicians, government agencies or police.
I lived there for a while and was really surprised at some things.
What really shocks me is that some ambulance chasing lawyers is trying to blame the manufacturer for a flaw, never mind that 3 crew with 3 sets of eyes allowed the airspeed to fall 40 kts below VREF.
Then the press in this crash as others in Turkey are labeling the crew as some kind of martyrs.
People everywhere make mistakes, we all learn from them, but to take a mistake and try and blame others just to collect money wrongfully due is beyond me.
The R/A was a minor fault, not monitoring airspeed and altitude was a major failure which cannot be blamed on the aircraft or manufacturer.
They are proud people, of their country and culture, it is also well know to be very corrupt when it comes to anything such as this, money talks, if it goes into the pockets of the politicians, government agencies or police.
I lived there for a while and was really surprised at some things.
What really shocks me is that some ambulance chasing lawyers is trying to blame the manufacturer for a flaw, never mind that 3 crew with 3 sets of eyes allowed the airspeed to fall 40 kts below VREF.
Then the press in this crash as others in Turkey are labeling the crew as some kind of martyrs.
People everywhere make mistakes, we all learn from them, but to take a mistake and try and blame others just to collect money wrongfully due is beyond me.
The R/A was a minor fault, not monitoring airspeed and altitude was a major failure which cannot be blamed on the aircraft or manufacturer.
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Just ask some of the westerners with Orex Air cargo out of IST with the 747.
One Captain was fired for having the aircraft de-iced.
Several others were fired for asking for their pay after it was 2 months late.
They seem to have there own little world there with aviation.
Problem is that its does not comply with the way the rest of us are required to operate.
Maybe Turkish airlines is the best of the rest, but still something is wrong there.
http://www.pprune.org/freight-dogs/3...x-cargo-2.html
I do know some of these guys, everything posted is how most of the operations work there.
If you don't fly against the MEL or bust FDT limitations you can go home.
But this is Turkey!!!!!
If you can get away with something you are not considered to be wrong, just clever!
One Captain was fired for having the aircraft de-iced.
Several others were fired for asking for their pay after it was 2 months late.
They seem to have there own little world there with aviation.
Problem is that its does not comply with the way the rest of us are required to operate.
Maybe Turkish airlines is the best of the rest, but still something is wrong there.
http://www.pprune.org/freight-dogs/3...x-cargo-2.html
I do know some of these guys, everything posted is how most of the operations work there.
If you don't fly against the MEL or bust FDT limitations you can go home.
But this is Turkey!!!!!
If you can get away with something you are not considered to be wrong, just clever!
Last edited by Earl; 9th Apr 2009 at 19:04.
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While more or less all agree that a lapse in basic airmanship allowed the unnoticed left RA problem to trigger a series of issues, it does seem that it would be a good idea - and easy to achieve - to incorporate a system to flag up and announce a mismatch between the two RAs. It went unanswered, very early in this thread, that the left RA could only flag a failure but not an error while the right RA was sitting there waiting to have its measurement compared. Being electronic instruments, rather than pressure-operated, should make a comparison system relatively easy and cheap - both as original equipment but also, now, as a modification.
Last edited by Cameronian; 11th Apr 2009 at 18:50.