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Turkish airliner crashes at Schiphol

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Turkish airliner crashes at Schiphol

Old 9th Apr 2009, 20:19
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flyburg

Good point – got myself totally confused there between events pre- and post-FAS - so now your point makes complete sense! My apologies!

Was just having a break while Rotavating the lawn! Exhaustion led to complete brain failure! That’s my excuse.

Anyway, my Post now deleted as it is clearly bo**ox.

As you said, from FAS down to the shaker – that’s where it all did not add up!

Note to self - do not Post when shattered.

Off for a bath and a beer!

H ‘n’ H
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Old 9th Apr 2009, 20:27
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No worries,

Been there, done that.

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Old 9th Apr 2009, 20:48
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Automation failed the pilots.

I feel ,like the naked emperor but you proffessional pilots insist on hair shirts and blaming the aircrew.

As a proffessional control engineer (industrial) I have no hesitation in saying that the automation concept was prima facie to blame, and I am ashamed that such a tragic system was designed.

The automation FAILED, the pilots were RELYING on it and you must always be able to rely on it,until it detects a problem,announces it and relinquishes control. Any system which does not do this shoud never be installed in anything serious.

If the trim in my puddle jumper motors uninvited to full extent while I'm on a bumpy crosswind sun in eyes final over turb ridden sheds am I to blame for losing attitude control?
NO, I blame the b faulty switch and miniscule indicator,and more importantly the CONCEPT which motorised away my absolute authority over pitch,while I was otherwise occupied.

The architecture of this 'automatic' control is pathetic.
One RA should be in control of all parameters,any deviations would then affect all controlled functions,and there would be no need to spend invaluable time and distraction in trying to puzzle why some functions are OK and others incorrect,spurious alarms going off etc due to RAs inputting to different elements of control,and the pilots understandably unaware of what controls what,probably 'cos no one told them.

The other RA should input check data and when the two RAs differ beyond a certain amount,zowie,announce problem,hand back control.

atceng (retd)

Last edited by atceng; 9th Apr 2009 at 20:54. Reason: keyboard errors
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Old 9th Apr 2009, 21:16
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This whole RA thing obviously offends so many electronic design types who are posting.

The serious failure case is covered by Boeing - you cannot engage both autopilots for a Cat 3 approch and autoland if the RA system is not operating as it should. Any fault in the RA system at any other time is, to use Rainboe's word, trivial. Please understand that. There is nothing wrong with the system.

There are countless, possible trivial failures that can inconvenience an approach. Crew deal with them every day - it is part of the job. Maybe the windshield wiper packs up in heavy rain, maybe (God forbid) the autopilot drops out on intercepting the glideslope and you actually have to fly it yourself. In this particular case, disconnecting the autothrottle would have done it. It was, after all, telling them with a RETARD caption and by not applying power to maintain airspeed. What more warning do you need? The autopilot would have stayed connected. There was no technical problem. The problem was the crew not monitoring the approach - full stop.

Hopefully we shall learn why they did not monitor the approach but to criticise the RA system is not helpful.

Last edited by foresight; 9th Apr 2009 at 21:29. Reason: additions
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Old 9th Apr 2009, 21:40
  #2185 (permalink)  
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atceng;
As a proffessional control engineer (industrial) I have no hesitation in saying that the automation concept was prima facie to blame, and I am ashamed that such a tragic system was designed.

The automation FAILED, the pilots were RELYING on it and you must always be able to rely on it,until it detects a problem,announces it and relinquishes control. Any system which does not do this shoud never be installed in anything serious.
Well, you need to do just that: hesitate and think. Before launching, you need to understand the nature of the failure here. Radio Altimeter "failures", while not a regular occurence, are, and should be, a complete non-issue to a professional airline crew. It is, please understand, simply a non-event.

What is serious and has not been addressed by engineers but has been addressed by airlines, (in terms of emergency SOPs), is blocked pitot tubes and/or static ports. That issue will cause and has caused accidents; this very issue wrote off a perfectly serviceable $2b B2 bomber if you'll recall. That is an issue worth discussing; this one is most certainly not except for why this crew didn't fly their aircraft.

The plain fact is, this crew did not do their job; they abdicated their professional responsibilities and killed some of their passengers, because they stalled their aircraft, because, for whatever reason, they did nothing about a degrading airspeed. As someone else said, the CVR will tell the story but most bet we'll never read a transcript.

This crews' failure is in the same categorical nature and quality of professional failure that an engineer would be if s/he were to ignore/forget/mistake material strengths or span fracture mechanics. It is truly no more complex than that.
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Old 9th Apr 2009, 21:49
  #2186 (permalink)  
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If you're referring to the Birgenair, that accident has an interesting twist/component to it as well which is left to others to discover.

Yes, basic airmanship was absent in that accident. The Aeroperu accident was more difficult to handle in terms of basic airmanship. That said, there were ways out for both, but both were far longer shots at success than this crew gave themselves and their passengers.
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Old 10th Apr 2009, 03:58
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I'm not 'pushing' anything. The trend has been to improve automation. In another generation they may well be there. What this accident has done is to increase the impetus to design the human element out of the system since in several incidents it has shown that occasionally, it cannot match up to the automation. If it doesn't work as a final protection when it is rarely needed, what is the point of having it there in the first place? I was angry when I read Learmount's article, but by the end of it, I had to concede he does have a point.
Quite the opposite Rainboe !

No crew in that aircraft and automation brings it down all the same.
That crew also failed but how many crews would have properly intervened.
I believe every single day pilots take over automation but as they do nobody hear about it.

The answer is not by keeping the pilots out the cockpit but by limiting the level of automation and by proper and regular training.
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Old 10th Apr 2009, 04:32
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Glueball said:

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.
That one statement pretty much explains why these type of accidents occur, someone screws up and we try to go back or invent a procedure. Procedures will never substitute for awareness. Another cry that is heard is 'monitor the automation, read the FMA'. They are both inherently wrong statements too. What should be done is to check the automation mode desired is selected and then 'monitor the performance instruments' to make sure the aircraft is doing what you wish. Whatever happened to 'selective radial scannning'? Basically the introduction of the PFD!
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Old 10th Apr 2009, 06:59
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sticky: Turkish Crash Forum

I am having trouble keeping up with his Turkship, and his incidents and accidents, is it now time for a Turkish sticky...........
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Old 10th Apr 2009, 07:52
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@rainboe

No mercy should be shown to find out 'why?'
As you have (I think) previously suggested, there may be no helpful answer to "Why?".

It may well be there was simply a 10^-9 simultaneous and sufficiently protracted failure by all three pilots to remember what they were there for.
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Old 10th Apr 2009, 10:01
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What really shocks me is that some ambulance chasing lawyers is trying to blame the manufacturer for a flaw,
Why would that shock you? That is exactly what "ambulence chasing lawers" do - go after the deep pockets.
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Old 10th Apr 2009, 11:13
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While I broadly agree with the feeling of shock that an accident like this can happen, doesn't the history of such accidents show us that we will always react like this? (In judging the crew harshly). "How could they do this" rather than "there but for the grace of god...." Until the next one. Or even worse, until we ourselves make a 'human error'?

Isn't this the whole point of human factors - that we are all fallible? When the holes in the cheese line up.............

If I've read the Boeing publication correctly, the speed decayed from normal to Vref-40 in 30 secs. We don't know what distractions occured during those 30 secs.

This is not to excuse negligence if that is the case, but on the other hand, can any of us truly say that in our whole flying career we have never been distracted in such a way? For 30 secs?

I agree that a rad alt failure is a total non-event - I'm sure I've had loads of erroneous displays over the years.

But like all similar accidents, it's the subtle interplay of all the factors that bring us inexorably to the disastrous consequences.

At the beginning of this thread I felt more judgemental on the crew. Now I feel 'who knows'? We need the specifics of the distraction in those 30 secs when the last holes in the cheese lined up to truly learn from this accident.

I'm sure the fact of it being a training flight will play a big part.
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Old 10th Apr 2009, 12:48
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Isn't this the whole point of human factors - that we are all fallible?
Yes. But where does fallibility cross into negligence? If you drive down the road at 100 mph on the 'phone while looking for a track on your iPod and have an accident, is that 'human factors'? Both drivers and pilots undergo instruction/training and are expected to reach a certain level of basic competence like: "don't let go of the steering wheel" and "always fly the airplane".

...can any of us truly say that in our whole flying career we have never been distracted in such a way? For 30 secs?
At 100W, possibly. On short finals to a busy airport in IMC? No, I haven't and I expect the majority share this view. Close to the ground the flightpath of the aeroplane needs continual monitoring, which there appears to have been a complete absence of in this case.

When I read incident/accident reports, I almost always learn something useful that hopefully stops me following in their footsteps. Going with what information has been released so far, this accident appears that it will contribute precious little to the sum of aviation knowledge, apart from the extremely obvious.
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Old 10th Apr 2009, 13:59
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It is pointless discussing whether or not we 'super-heroes' have or have not been distracted for 29 or 31 seconds on finals (borrowed '!'). We are all human (well. most of us) and surely the lesson here is that IF there is such 'distraction', we must not allow it to eliminate the monitoring of the 'vital signs' of aviation life. If it does so, the only remaining course of action is to break off the particular manouevre which we are attempting.

In the case of Schipol, if there were such a distraction, it must have been significant to stop 3 pairs of eyes from seeing, in which case one reasonably expects a TC to grasp the nettle and take positive action.
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Old 10th Apr 2009, 14:02
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Look at SE Asia. Aviation has gone seriously wrong in some countries. Curiously, it's the one that can lay the blame on someone else. What's the expression? 'Insha'allah' or something? 'God will provide' or 'in the hands of God'. Bit of a shame on the passengers when he doesn't provide! The passengers are relying on the pilots, not provision from above.
You are generalizing.
There are only two countries with a Muslim majority
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Old 10th Apr 2009, 14:10
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When I read incident/accident reports, I almost always learn something useful that hopefully stops me following in their footsteps. Going with what information has been released so far, this accident appears that it will contribute precious little to the sum of aviation knowledge, apart from the extremely obvious.
Where I believe it will contribute however, is to the sense of how much distraction you allow. We all get distracted and as many on this thread have said it's a question of how long before we come back to the duties at hand.

After each such episodes of distraction in the future you can now think about how long it took you to come back to the critical tasks and judge your own performance thinking about this accident.
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Old 10th Apr 2009, 17:58
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Let me venture into the lions den. Automation has made all our lives safer and easier in many fields and is here to stay.

Rainboe is of course right, there are certain things that are so basic that they should never be lost sight of. There can never really be an excuse for this.

On the other hand it does seem, from all the comments here that in highly automated multimode systems, mode confusion can be a serious problem for the operator, particularly in unusual situations.

In mode A then X, Y and Z are attended to, in mode B, X and Z but not Y, in mode C, X alone and so on.

This demands constant full awareness of the current mode, what it does, when it will transition to another mode and why, and what will happen when assorted inputs are degraded either individually or together.

I would venture that such constant awareness while monitoring the automatics is less "natural" than the immediate focus of hand flying where matters may be more predictable and immediate.

But obviously this is part of a modern ATPL pilot's training.
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Old 10th Apr 2009, 19:14
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If I've read the Boeing publication correctly, the speed decayed from normal to Vref-40 in 30 secs. We don't know what distractions occured during those 30 secs.

This is not to excuse negligence if that is the case, but on the other hand, can any of us truly say that in our whole flying career we have never been distracted in such a way? For 30 secs?

I agree that a rad alt failure is a total non-event - I'm sure I've had loads of erroneous displays over the years.
Did the aircraft meet the stabilized approach criterion at 1000 ft? I think this crew "lost it" well before those 30 secs to Vref-40.
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Old 10th Apr 2009, 19:29
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Did the aircraft meet the stabilized approach criterion at 1000 ft?
The only stand-out item would probably be the TL's being at idle annunciated only by the RETARD caption, speed and configuration would likely have been within limits at that point.

If bitchin betty could be programmed to issue a stabilized approach criterion warning - "UNSTABLE APPROACH - POWER LEVERS IDLE", that could have been enough to wake them up and save the flight and some lives. But the suggestion has been shot down already on this thread by the purists who want to see the crew swing and lowly Boeing shielded from any implication that their Auto Thrust design on the 737NG might be less than optimal.
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Old 10th Apr 2009, 19:49
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Ok, lets put a spin on this accident!
If the Turks, Lawyers etc are saying its a Boeing design defect and not pilot error.
What will happen to the previous Turkish Airlines crews that did not report this problem as the FDR showed, and nothing entered in the maint logbooks?
Two sides to every story then there is the truth !!!
Points right back at them no matter how its seen.
Bad Airman ship, little regard for the basics, sleep at the wheel.
A good Boeing lawyer will eat them for lunch.

Last edited by Earl; 10th Apr 2009 at 20:06.
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