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Turkish airliner crashes at Schiphol

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Turkish airliner crashes at Schiphol

Old 12th Apr 2009, 00:00
  #2221 (permalink)  
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BarbiesBoyfriend;

Not meant to be clever at all but was actually an outcome of your earlier post which I thought summarized things really well - I thought the points you made were worth taking up and it just grew.

The key here is I think, the discussion on what is happening to our industry has found it's home, triggered by this fatal accident. This discussion belongs to flight crews first, then operations managers next, then the regulator. This is the kind of dialogue that should be taking place right now, in offices, cockpits and board rooms.
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Old 12th Apr 2009, 00:22
  #2222 (permalink)  
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PJ
I think the dialogue you hint at is taking place.

But until I see it transcribed, I'll remain unconvinced.

The real deal is how do you/we put back into the pilots all that good stuff that we've spent 10 years taking out?

Wish I knew.

Happy landings!

(btw I was 5 miles behind the THK when it went in.....quite upsetting even though we were not involved)
 
Old 12th Apr 2009, 01:13
  #2223 (permalink)  
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BarbiesBoyfriend;

I hope the dialogue is begun as well. It will, sooner or later anyway.
btw I was 5 miles behind the THK when it went in.....quite upsetting even though we were not involved
Yes, upsetting indeed. I understand - we were next behind Eastern 66 when he went in at Kennedy.
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Old 12th Apr 2009, 07:11
  #2224 (permalink)  

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PJ2

Very fine analysis. The same (with somewhat different but equally disturbing manifestations) is taking place in the field of graduate and postgraduate specialist medical training and practice.

Not good.

Mac
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Old 12th Apr 2009, 07:36
  #2225 (permalink)  
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I believe we should not try to draw too many lessons or inferences from this accident
As you suggest, there are many of us who agree that the discussion surrounding the Schipol accident has cracked open a dialogue that should continue.
My reasoning is, this is the statistical one in 10 million. It was caused by a totally negligent crew from a background of 'Far Eastern' type operators (I see elements of certain Chinese/Korean/Indonesian practices with this outfit). Frankly I do not see many lessons of value to Western operators in this accident- what in particular happened incredibly rarely happens elswhere. Behind this accident is a culture that contributed directly to it. It will take generations to change that culture, and in the meantime, next time a Indonesian carrier is a a darn hurry to land, the Captain will take it in, and the Co-pilot will sit there semi-mute, unable to interject until they crash. I don't believe any lessons are to be learned here for normal operators, but we are all still going to have to go through a one hour presentation thanks to it. This was the statistical exceptionaly rare event, and I don't believe we can ever completely rub it out. Those that provide the exceptionaly rare events come from a particular set- they must learn the lessons. There is little in this accident for the rest.
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Old 12th Apr 2009, 07:52
  #2226 (permalink)  
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PJ - I also heartily endorse your excellent appraisal of where we are today. I feel, like Grizzled,, however, that it is in danger of being lost here in the welter of shouting about the 'dumb pilots' and the failure of the a/c systems, and would also suggest starting another thread away from all the hubble bubble here.

The only point with which I take issue with you on is "This discussion belongs to flight crews first, then operations managers next, then the regulator." where I would reverse the order, since I firmly believe that the sausages coming out of the machine are created by that reverse order. I am fairly certain, having been a military pilot (although I do not know the military backgrounds of the THY crew), that some significant influence on the behavoural patterns caused the apparent lack of attention to flying the a/c, and I'm sure this can be traced back further than 'Laurel and Hardy'. You don't suddenly 'lose' years of self-preservation just like that.

I would appreciate a PM with links to the other discussion fora (the mods here really hate those 'in public').

Barbie - Post #2293 - so right!

Last edited by BOAC; 12th Apr 2009 at 11:35.
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Old 12th Apr 2009, 08:57
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Mac The Knife

Mac The Knife

'The same (with somewhat different but equally disturbing manifestations) is taking place in the field of graduate and postgraduate specialist medical training and practice'.

Not limited to your fields only. Ask anyone involved in oil & gas engineering/construction.
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Old 12th Apr 2009, 11:19
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I see 'bulletproof' guys more and more and they give me the freakin' shivers.
BarbiesBoyfriend, my sentiments also. My hallucination is that I see people that lack imagination about what can or might happen.

I have said it before but there is a difference between doing "things right" (aka management) and doing the "right thing" (aka leadership).

There seems to be much of the "tick in the box" philosophy instead of asking "Is this really going to ensure flight safety?".

About 35 years ago I recall reading a book called "The Safe Airline". One quote always remember from it was that one person high in flight safety said something like "The airlines will tell you that flying is safe because the accident rate is so low. However I am much more interested in the reasons behind the accidents which do occur". I think the later discussions on this thread are highlighting this aspect.

I also recall that in the late 1960s Boeing were concerned about the accident rate in certain airlines. As a result of this they made certain items a mandatory fit on the a/c (whereas before they were optional), and all initial conversion and line training would be done by Boeing flight instructors - and this would be part of the package of buying a new Boeing. Much of this still takes place today of course but I wonder to what extent a/c manufacturers express their views about the safety culture and operations of companies such as Turkish.

I do feel we are at some sort of watershed and unless action is taken I fear we might see further accidents of this nature rather than less.
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Old 12th Apr 2009, 13:37
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Fireflybob

I do feel we are at some sort of watershed and unless action is taken I fear we might see further accidents of this nature rather than less.
Well of course you are correct. Increased operations means increased accidents for all causes. What we are trying to do is to lower the rate per flying hour so that the rate per week looks flat to the flying public. Lots of contributions to this rate and some of the biggies are being worked quite successfuly. Unfortunately that will leave accidents like the subject of this thread as standouts.

In its overall contribution it had not been as significant as CFIT and it doesn't lend itself to technology as well. So what is needed is a process like "best practice" etc. and of course a willingness to incorporate it. All the talk on this board will not get us there unless we lead others by the hand and not just tell them that they are wrong.
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Old 12th Apr 2009, 13:48
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My reasoning is, this is the statistical one in 10 million. It was caused by a totally negligent crew from a background of 'Far Eastern' type operators (I see elements of certain Chinese/Korean/Indonesian practices with this outfit). Frankly I do not see many lessons of value to Western operators in this accident- what in particular happened incredibly rarely happens elswhere. Behind this accident is a culture that contributed directly to it. It will take generations to change that culture, and in the meantime, next time a Indonesian carrier is a a darn hurry to land, the Captain will take it in, and the Co-pilot will sit there semi-mute, unable to interject until they crash
Rainboe. Well done for calling a spade a spade. In my experience you are one hundred percent correct. I have seen many unbelievable examples of poor flying ability by various nationalities in the simulator. Yet, try as I might to be scrupulously fair in my assessement, invariably the common demoninator was exactly as you have described, except we are not allowed talk about it aloud for fear of crossing the boundaries of political correctness.

Last edited by A37575; 12th Apr 2009 at 13:58.
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Old 12th Apr 2009, 18:58
  #2231 (permalink)  
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Rainboe;

The point you raise is an appropriate one to consider. My needle is not stuck on narrow issues. I just think the discussion is valid on the basis f the observations made and apply broadly and not just to aviation, or to any one company. I discuss it here only because it has implications and consequences for the presently-low fatal accident rate. We have heard for some time now at conferences, in papers and on websites that, (notwithstanding the effects of the present economic situation), just maintaining the accident rate won't good enough to keep the line flat. It will climb purely as a matter of percentages alone. That matter is not addressed in the thinking and awarenesses described in the post above.

While the AMS accident may be a "once-off" or perhaps a trend within either a culture, part of the world or an airline, two other accidents outside those areas captured by your observation remain: The Madrid accident and the Buffalo accident. The Madrid one is of a slightly different quality in terms of the errors made I know, and we do not yet have definitive data on the Colgan accident. Crew experience and airline safety culture/SOPs/training regimes may or may not have played a role in both/either.
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Old 12th Apr 2009, 21:28
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Just a basic question I have about the malfunctioning altimeter and auto-throttle: Can the captain not have simply DISEGAGED JUST THE AUTO-THROTTLE and still kept the horizontal LNAV engaged (with autopilot still on, of course)? This would have simply returned control of thrust to the captain on full manual and still kept the lateral navigation active so the plane remained properly aligned with the centre of the runway. Since the visibility was very poor, this would have been an advantage for the crew so they did not lose sight of the runway centre but still had to control the thrust and vertical descent rate.

Is this possible at the final approach before landing? I mean, will the ILS signal still guide the plane properly to the centre of the runway laterally if VNAV is disengaged?

Just curious...

John
 
Old 12th Apr 2009, 22:06
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Can the captain not have simply DISEGAGED JUST THE AUTO-THROTTLE and still kept the horizontal LNAV engaged (with autopilot still on, of course)?
I am sure he could, but would have required him to notice the ATHR was not working / the speed was low

I mean, will the ILS signal still guide the plane properly to the centre of the runway laterally if VNAV is disengaged?
I am not a 73 pilot, but woukd be very surprised if a 737 makes a coupled approach in LNAV / VNAV I would think it would be like the Airbus in some sort of LOC / G/S modes...

Personally, if you are well down a glideslope, the ATHR "fails" (or seems to) and/or the speed get seriously low, your priority is probably not to figure out a way to continue the approach. I would suggest you throw it away / go-around, fly the aircraft first, then diagnose the problem and get both your SA back as to what is/was going on.... but as I said above, that relies on you noticing the "problem" in the first place.

NoD
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Old 13th Apr 2009, 01:12
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Byma - all the pilot would have had to do was actually push the thrust levers forward - i.e over ride the A/T in its attempt to bring the levers back to idle!! The autoflight systems would have held the LOC and GS.
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Old 13th Apr 2009, 02:19
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Yes, it was an elementary recovery, just push the throttles up to maintain approach speed. But they didn't.
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Old 13th Apr 2009, 04:36
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Well they did manage to push the PL's up in an attempt to recover the aircraft at stick shaker, but the still malfunctioning RA caused the AT to command them back to idle. With the result that they hit the ground in a tail low attitude short of the runway. Maybe not so easy or elemental after all?
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Old 13th Apr 2009, 06:03
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One of the family has emailed me this item which refers to a similar incident on a Qantas flight, by Geoffrey Thomas on ATW online today.

Qantas and the Australian Transport Safety Bureau said they will consult with and assist Dutch crash investigators after a QF 737-800 last week suffered a radio altimeter malfunction similar to the one that is suspected of causing the loss of a Turkish Airlines -800 on approach to Amsterdam on Feb. 25.
Qantas Flight 1020, an -800 operating from Hobart to Sydney on April 7, experienced the radio altimeter fault on approach. According to a QF spokesperson, the -800 was "at approximately 100 ft. when the captain's radio altimeter indicated that the aircraft was at around 10 ft., about where the auto thrust activates full retard on the throttles."
As in the THY crash, the captain's altimeter was indicating a different set of data than the first officer's <http://www.atwonline.com/news/story.html?storyID=15812>(ATWOnline, March 5). "Upon noticing the fault, the captain immediately disconnected from the auto thrust and manually flew the aircraft into Sydney," the spokesperson said. "It is Qantas flight operations policy for pilots to guard the thrust levers and fly with hands on the levers when the aircraft is on auto, which ensures that should a fault with the thrust levers occur, the pilots are immediately able to fly manually."
The carrier self-reported the incident to ATSB, which confirmed it will investigate due to the similarity of the fault to the assumed cause of the THY crash. The QF spokesman told ATWOnline that "there is no suggestion by the ATSB that Qantas or its pilots were at fault. This investigation is simply to assist European regulatory authorities."
A preliminary investigation by the Dutch Safety Board revealed that the only fault discovered on the aircraft was in the captain's radio altimeter, which suddenly changed from 1,950 ft. to read -8 ft. in altitude although the right-hand altimeter functioned correctly.
by Geoffrey Thomas
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Old 13th Apr 2009, 09:28
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Mu3001a

Still very 'elemental'. The PF should have his hands on the thrust levers at this stage of the flight. You can easily overide the A/T if it is trying to close them, or do you sit there do nothing and hit the ground. Elemental and basic airmanship.
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Old 13th Apr 2009, 12:31
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@cessnapete

Still very 'elemental'. The PF should have his hands on the thrust levers at this stage of the flight.
Well dohhh! So which bit of this in the immediately preceding post eluded you cessnapete?

"It is Qantas flight operations policy for pilots to guard the thrust levers and fly with hands on the levers when the aircraft is on auto, which ensures that should a fault with the thrust levers occur, the pilots are immediately able to fly manually."
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Old 13th Apr 2009, 13:30
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Well they did manage to push the PL's up in an attempt to recover the aircraft at stick shaker, but the still malfunctioning RA caused the AT to command them back to idle. With the result that they hit the ground in a tail low attitude short of the runway. Maybe not so easy or elemental after all?
At this already very degraded stage it was not easy at all anymore.
Only an excellent team work would have saved the situation :
PF needed both hands on the control wheel to fight the enormous pitch up moment and at the request of the PF, the PNF should have maintained both power levers in the dash.

Much earlier in the approach one hand on the power levers would have helped to detect the inappropriate low power request ...
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