Turkish airliner crashes at Schiphol
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I cannot but agree with the posts of my colleagues and peers regarding the input of SFLY .. a check on previous posts appears to point to an ill informed and rigidly viewed, attention seeker.
TR
TR
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If I may be allowed to contribute to the wholly justified tearing off of a strip, I thought his attitude, & somewhat insistent nit- picking infantile questioning to the actual Capt of BA038 on the relevant thread, and the patience shown towards him by the self same Capt , told you all you needed to know about the two men.
Graybeard;
Not picked on at all...good question and to the point of the discussion about automation, what it is to be a pilot and current trends in the industry of which this may be one iteration; the perspectives offered by a history will tell us.
I understand what you're driving at and agree that the loss of speed was caused by the autopilot trying to maintain the glideslope and that neither the autothrust nor the crew intervened.
Let us take this back further, given that nothing occurs here without antecedent.
What is the antecedent cause of such non-intervention by the autothrust and the crew? In the autothrust case, it was the incorrect data from RA1. What is it for the crew?
Here, the thrust levers actually move and so provided tactile and visual cues indicating that idle thrust was being commanded. That made sense, for a while, but not forever. When the thrust levers were pushed forward for more thrust as speed decreased, they returned to the idle position and remained there for the duration of the sequence until the crew responded essentially when there was little opportunity for a successful recovery. Why?
The broader issue is of course automation complacency and is huge and growing, (not without many cautions and warnings from experienced crews).
In reference to you question about how to posit the causal factors, do we cross the line and accept that it was indeed just the autothrust which "failed" to intervene and leave it at that? I think that opens the door quite wide to those who adhere to the notion more, not less automation is "required". I have seen decisions within flight operations which, after a serious "hand-flown" incident, have required the increased use of automation to "prevent" such incidents. We can all think of some circumstances where this is absolutely the case (making things safer), but at what cost in the overall scheme? At some point, muscles atrophy if not used...
Do we design warnings for failure of warning systems? In such case, the call for "warnings" of such non-intervention (by the autothrust or the crew) may in some way be obvious but then how far does the regression go? Is it to be "warnings of non-operating systems", all the way down? The Takeoff Configuration Warning system on the MD82 at Madrid was a single-point failure waiting to occur. Is there a requirement for warning the crew that the warning system is itself compromised? And when we get to a reasonable (vice theoretical regression!) end, what is asked for is enhanced crew attention to the matter anyway.
We know humans are poor monitors and much better "controllers" when engaged physically and mentally with the tasks at hand. I had at one time considered (philosophied) one very simplistic notion which would turn monitoring and operational tasks (flying/controlling the aircraft), around - the "airplane" (rather its autoflight system), becomes the monitor and the crew becomes the operator. Such a system "mimics what is normal in all flight regimes" in terms of human-controlled/operated flight (sampling vast amounts of "normal" data), and may even anticipate solutions to flight circumstances for comparison with what the crew does. When flight brushes up against the many, many boundaries that may be established, progressive warnings emerge as may be appropriate. I fully realize the complexity philosophical shifts necessary for such a change and it probably isn't necessary given the relative, very high success rate of the present solutions.
Returning to THY1951, the causal pathway to stickshaker must somehow be set out such that both the technical and human factors issues are addressed. The fact that this same scenario has occurred twice speaks to the urgent need to address both issues but the singular issue of automation complacency is a fundamental outcome of the direction the industry has taken. In my view, pilot Associations have had a role to play here and have not provided as robust a response as might be expected given the depth of feeling seen here and elsewhere, but the issue certainly doesn't stop there. I sense we are going to see a re-trenching by the manufacturers but given that we have gone to two-man crews, (Cost, not safety were the original driving force for automation solutions), and have now two generations trained in autoflight priorities and operations, such a shift will necessarily have to bridge automation and human factors, (ach!, such a large term - almost meaningless), rather than pioneer new solutions. PJ2
Not picked on at all...good question and to the point of the discussion about automation, what it is to be a pilot and current trends in the industry of which this may be one iteration; the perspectives offered by a history will tell us.
Would it not be more better to say? "For whatever reason, the salient fact here is, over a time period of 100 seconds, the autopilot caused the aircraft to lose more than 40kts of airspeed in the very late stages of the approach phase, in the attempt to stay on glideslope, and neither the autothrottle nor the crew intervened.."
Let us take this back further, given that nothing occurs here without antecedent.
What is the antecedent cause of such non-intervention by the autothrust and the crew? In the autothrust case, it was the incorrect data from RA1. What is it for the crew?
Here, the thrust levers actually move and so provided tactile and visual cues indicating that idle thrust was being commanded. That made sense, for a while, but not forever. When the thrust levers were pushed forward for more thrust as speed decreased, they returned to the idle position and remained there for the duration of the sequence until the crew responded essentially when there was little opportunity for a successful recovery. Why?
The broader issue is of course automation complacency and is huge and growing, (not without many cautions and warnings from experienced crews).
In reference to you question about how to posit the causal factors, do we cross the line and accept that it was indeed just the autothrust which "failed" to intervene and leave it at that? I think that opens the door quite wide to those who adhere to the notion more, not less automation is "required". I have seen decisions within flight operations which, after a serious "hand-flown" incident, have required the increased use of automation to "prevent" such incidents. We can all think of some circumstances where this is absolutely the case (making things safer), but at what cost in the overall scheme? At some point, muscles atrophy if not used...
Do we design warnings for failure of warning systems? In such case, the call for "warnings" of such non-intervention (by the autothrust or the crew) may in some way be obvious but then how far does the regression go? Is it to be "warnings of non-operating systems", all the way down? The Takeoff Configuration Warning system on the MD82 at Madrid was a single-point failure waiting to occur. Is there a requirement for warning the crew that the warning system is itself compromised? And when we get to a reasonable (vice theoretical regression!) end, what is asked for is enhanced crew attention to the matter anyway.
We know humans are poor monitors and much better "controllers" when engaged physically and mentally with the tasks at hand. I had at one time considered (philosophied) one very simplistic notion which would turn monitoring and operational tasks (flying/controlling the aircraft), around - the "airplane" (rather its autoflight system), becomes the monitor and the crew becomes the operator. Such a system "mimics what is normal in all flight regimes" in terms of human-controlled/operated flight (sampling vast amounts of "normal" data), and may even anticipate solutions to flight circumstances for comparison with what the crew does. When flight brushes up against the many, many boundaries that may be established, progressive warnings emerge as may be appropriate. I fully realize the complexity philosophical shifts necessary for such a change and it probably isn't necessary given the relative, very high success rate of the present solutions.
Returning to THY1951, the causal pathway to stickshaker must somehow be set out such that both the technical and human factors issues are addressed. The fact that this same scenario has occurred twice speaks to the urgent need to address both issues but the singular issue of automation complacency is a fundamental outcome of the direction the industry has taken. In my view, pilot Associations have had a role to play here and have not provided as robust a response as might be expected given the depth of feeling seen here and elsewhere, but the issue certainly doesn't stop there. I sense we are going to see a re-trenching by the manufacturers but given that we have gone to two-man crews, (Cost, not safety were the original driving force for automation solutions), and have now two generations trained in autoflight priorities and operations, such a shift will necessarily have to bridge automation and human factors, (ach!, such a large term - almost meaningless), rather than pioneer new solutions. PJ2
Last edited by PJ2; 6th Feb 2010 at 19:46.
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Well, here is where I stand on all this fluff.
I really would like (and it appears to have 'died') any attempt to directly compare this accident with the 777 at LHR to cease.
I really would like (and it has not yet happened) that we stopped trying to argue aviation sematics/experience/mine's bigger than yours and just got on with taking all inputs, reading them and if they are worthy of reply, doing so. We have pages of attack and reply, none of which have contributed one iota to learning more lessons from this sad accident. In our own, much less important way we are here guilty of 'not minding the shop' and allowing distraction from the task - which appears to be the very thing we accuse the THY crew of.
Moving on: The idea of limiting tail trim has in my opinion a lot of merit. I believe it was aired on the A320 PGF accident thread? There is no reason on earth why a pilot should not be made to strain his/her muscles IF they want to reduce speed below Vref in the air. I personally would favour a clear - loud and visible - warning that 'limit trim' has been reached and a killing of the trim motor at that point in that direction until speed is increased. I'm sure it would have prevented several previous 'subtle' speed reductions below sensible limits.
I really would like (and it appears to have 'died') any attempt to directly compare this accident with the 777 at LHR to cease.
I really would like (and it has not yet happened) that we stopped trying to argue aviation sematics/experience/mine's bigger than yours and just got on with taking all inputs, reading them and if they are worthy of reply, doing so. We have pages of attack and reply, none of which have contributed one iota to learning more lessons from this sad accident. In our own, much less important way we are here guilty of 'not minding the shop' and allowing distraction from the task - which appears to be the very thing we accuse the THY crew of.
Moving on: The idea of limiting tail trim has in my opinion a lot of merit. I believe it was aired on the A320 PGF accident thread? There is no reason on earth why a pilot should not be made to strain his/her muscles IF they want to reduce speed below Vref in the air. I personally would favour a clear - loud and visible - warning that 'limit trim' has been reached and a killing of the trim motor at that point in that direction until speed is increased. I'm sure it would have prevented several previous 'subtle' speed reductions below sensible limits.
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The 737 trim wheel is generally a fairly noisy thing (although it does vary from airframe to airframe). Not quite as aural, if memory serves me well, as the seal -in-pain on the DC9 (or am I getting senile ? ) but nonetheless, generally fairly obvious.
What has happened to our appreciation of the subtleties around us . . . . a trim wheel that keeps turning / airspeed noise that seems to be getting quieter/ engine noise that seems to be missing
. . . . yes yes, distraction, rushed approach, training. . . . but really, if you have some empathy for this job, you should also have a "feeling" for when something just isn't right, and this approach couldn't have felt (to anyone with any sensitivity to what they are flying - be it manually or automatic ) anywhere remotely close to right.
I would never have the temerity to say "no matter the circumstances this could never happen to me ", but I can say without any doubt that this crew (for whatever reason yet to be revealed) were assuredly not on the case.
Whatever conclusions, excuses, accusations have or will be drawn on this, I believe that the only important lesson/mystery to be pursued is . . . . why the hell didn't the drivers realise & react in a timely fashion to the fact it was all going to a crock of sh1t ? ?
What has happened to our appreciation of the subtleties around us . . . . a trim wheel that keeps turning / airspeed noise that seems to be getting quieter/ engine noise that seems to be missing
. . . . yes yes, distraction, rushed approach, training. . . . but really, if you have some empathy for this job, you should also have a "feeling" for when something just isn't right, and this approach couldn't have felt (to anyone with any sensitivity to what they are flying - be it manually or automatic ) anywhere remotely close to right.I would never have the temerity to say "no matter the circumstances this could never happen to me ", but I can say without any doubt that this crew (for whatever reason yet to be revealed) were assuredly not on the case.
Whatever conclusions, excuses, accusations have or will be drawn on this, I believe that the only important lesson/mystery to be pursued is . . . . why the hell didn't the drivers realise & react in a timely fashion to the fact it was all going to a crock of sh1t ? ?
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Where are the details?
I am not asking this question as a criticism nor am I trying to start or continue any political discussion. As I read these discussions (every one in detail) I am surprised that there is still such a wide range of disagreement about the facts concerning what actually happened. Who did what when? I am not asking WHY – just who, what, when.
Why has almost a year gone by with no apparent agreement among pilots and professional aviation experts as to what events transpired in the cockpit, ATC, computers, mechanical equipment, engines, avionics?
Is there a technical reason a computer-generated analysis/recreation of the event has not been made available, similar to what I saw for Buffalo/Colgan?
The FDR/CVR were recovered within hours, the radar data is available, all radio transmissions were recorded and available, ground personal and pilots saw the event – yet there is no agreement as to exactly what happened and when. I read arguments about gates entered/not entered, throttle settings made/ignored/not ignored/not made, rate of descent, AoA,…etc, no one has heard the CVR or ATC communications. Those are simple incontrovertible facts with no judgmental, emotional, or political content– why haven’t those facts been made public?
Please explain why it is taking so long to tell us the exact actions taken by pilots, ATC, and the conversations that occurred. Those actions and conversations were recorded in fantastic detail – yet there is no public release of that data. It seems to me the facts can not be altered and will be made available at some point so why not get them out as soon as possible and put to rest much speculation.
Is there some technical problem with making all the facts known?
Why has almost a year gone by with no apparent agreement among pilots and professional aviation experts as to what events transpired in the cockpit, ATC, computers, mechanical equipment, engines, avionics?
Is there a technical reason a computer-generated analysis/recreation of the event has not been made available, similar to what I saw for Buffalo/Colgan?
The FDR/CVR were recovered within hours, the radar data is available, all radio transmissions were recorded and available, ground personal and pilots saw the event – yet there is no agreement as to exactly what happened and when. I read arguments about gates entered/not entered, throttle settings made/ignored/not ignored/not made, rate of descent, AoA,…etc, no one has heard the CVR or ATC communications. Those are simple incontrovertible facts with no judgmental, emotional, or political content– why haven’t those facts been made public?
Please explain why it is taking so long to tell us the exact actions taken by pilots, ATC, and the conversations that occurred. Those actions and conversations were recorded in fantastic detail – yet there is no public release of that data. It seems to me the facts can not be altered and will be made available at some point so why not get them out as soon as possible and put to rest much speculation.
Is there some technical problem with making all the facts known?
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BOAC, well said. Also a pilot in tune with the automation and being able to transition to hand flying with confidence would not add go around power to the limit until he manually had trimmed the aircraft to handle max power.
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BOAC, what you suggest makes sense from an aerodynamical point of view; prevent the plane from trimming itself into a corner from where it's hard to escape. I would suggest to limit the trim to the point where full TOGA power can be given and the plane can be kept under control at stall-speeds and attitudes. (One of the issues that played in this accident is that the 737-NG engines can overpower its controls.)
When you limit trim, it would mean an Autopilot disconnect too; forcing the crew to take action... Would not have made much difference for BA038, where the crew (intuitively) was aware of problems (and with their engines they were incapable to GA). For Turkish 1951 it could have made a 200-300 foot (and some knots airspeed) difference to make a go around.
Putting up my system engineering hat; it certainly is possible to add "underspeed protection" or "overtrim protection" to an autopilot. It adds to complexity, introducing a new failure mode into the automation. (Consider inappropriate activation of the protection mechanism.) Should manual trim be allowed to override the protection?
When you limit trim, it would mean an Autopilot disconnect too; forcing the crew to take action... Would not have made much difference for BA038, where the crew (intuitively) was aware of problems (and with their engines they were incapable to GA). For Turkish 1951 it could have made a 200-300 foot (and some knots airspeed) difference to make a go around.
Putting up my system engineering hat; it certainly is possible to add "underspeed protection" or "overtrim protection" to an autopilot. It adds to complexity, introducing a new failure mode into the automation. (Consider inappropriate activation of the protection mechanism.) Should manual trim be allowed to override the protection?
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The recent amendment to FAR 25.1329 (Amdt. 25-119, Eff. 5/11/06) doesn't allow autopilots that can lead the airplane into dangerous situations. For example, the A/P can't have the authority to stall the airplane. This is the good news.
The bad news is that there is no requirement for retrofit into old airplanes.
The other bad news. The Advisory Circular that was issued simultaneously with the FAR amendment says that disconnecting the A/P as you reach stall is OK.
What the rule giveth, the advisory circular taketh away.
Goldfish85
The bad news is that there is no requirement for retrofit into old airplanes.
The other bad news. The Advisory Circular that was issued simultaneously with the FAR amendment says that disconnecting the A/P as you reach stall is OK.
What the rule giveth, the advisory circular taketh away.
Goldfish85
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With respect, I see the conversation has become "tracked". The key to any Human/machine exploit is not "better machine" nor is it "better pilot".
The absolute fulcrum is the quality of the interface between the two. Autotrim to this limit, power limit to this one, loud klaxon, tender murmur, We have on several threads uncovered everything relative to automatics/pilotage ad nauseum. A tool can make the outcome smooth, or even make it possible at all, or it can put you in the grass upside down.
Can there be a better example than here in Holland? Accomplished pilots miss several cues that should have got instant focus. Automation hypnosis? Distraction. A difficult and tense approach, but so what? I swear the problem is only going to get worse until people understand how to work with tools. Every pilot, every tool.
bear
The absolute fulcrum is the quality of the interface between the two. Autotrim to this limit, power limit to this one, loud klaxon, tender murmur, We have on several threads uncovered everything relative to automatics/pilotage ad nauseum. A tool can make the outcome smooth, or even make it possible at all, or it can put you in the grass upside down.
Can there be a better example than here in Holland? Accomplished pilots miss several cues that should have got instant focus. Automation hypnosis? Distraction. A difficult and tense approach, but so what? I swear the problem is only going to get worse until people understand how to work with tools. Every pilot, every tool.
bear
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The recent amendment to FAR 25.1329 (Amdt. 25-119, Eff. 5/11/06) doesn't allow autopilots that can lead the airplane into dangerous situations. For example, the A/P can't have the authority to stall the airplane. This is the good news.
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Accomplished pilots miss several cues that should have got instant focus.
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I've not previously heard anyone describe these pilots as "accomplished", especially bearing in mind their "achievements" in this particular case.
Some good stuff:
http://flightsafety.org/asw/nov09/asw_nov09_p20-23.pdf
Last edited by S.F.L.Y; 8th Feb 2010 at 08:43.
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I teach my guys one thing first and foremost, in fact it is virtually a rant; somebody is always flying the aircraft.
That's it.
If you have something you want to do that does not involve your total attention to aviating, "you have control."
All this very interesting chat about equipment failures, trim settings, distractions or what have you ignores the soundness of this basic tenet.
If you want something to write on your bathroom mirror in the morning while you ready yourself for work, try "Skin, tin, ticket."
That's it.
If you have something you want to do that does not involve your total attention to aviating, "you have control."
All this very interesting chat about equipment failures, trim settings, distractions or what have you ignores the soundness of this basic tenet.
If you want something to write on your bathroom mirror in the morning while you ready yourself for work, try "Skin, tin, ticket."
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the "polder crash "
For something totally new,
Just got the message, that, dutch lawyers are about to claim up to 20 million Euros for every passenger who suffered any damage on that unfortunate turkish airline flight. The money should come from.......... boeing, being a compensation for designing an unsafe aircraft........... ??!!
Rumour has it that the chief of the dutch NTSB more or less agrees (all rumours, (for the dutch NTSB part), nothing confirmed. I have flown flown both Airbus and Boeing and do NOT agree!!!!!!!!!!!
Anybody out there ........... to comment, cause i am a bit lost on this one.........................................
P.S.1 ( I am Dutch)
.......
P.S.2 Yeah.... right.......... lawyers are lawyers, but as pilots,..... what do we think?????
Just got the message, that, dutch lawyers are about to claim up to 20 million Euros for every passenger who suffered any damage on that unfortunate turkish airline flight. The money should come from.......... boeing, being a compensation for designing an unsafe aircraft........... ??!!
Rumour has it that the chief of the dutch NTSB more or less agrees (all rumours, (for the dutch NTSB part), nothing confirmed. I have flown flown both Airbus and Boeing and do NOT agree!!!!!!!!!!!
Anybody out there ........... to comment, cause i am a bit lost on this one.........................................
P.S.1 ( I am Dutch)
.......P.S.2 Yeah.... right.......... lawyers are lawyers, but as pilots,..... what do we think?????
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Well, my opinion:
€2 million is at the high end for "loss of income" for a seriously disabled person (40 year * €50.000 of wages). One may add cost of medical treatment to that, which can amount to a few million over the years in rare cases. Most people (the ones that walked away) would be fairly compensated with a few 1000s for damage to their luggage, hotel costs and spoiled holidays...
Dutch judges are sane, so those lawyers went venue shopping in the US.
no sorry
*noises from the bathroom*
€2 million is at the high end for "loss of income" for a seriously disabled person (40 year * €50.000 of wages). One may add cost of medical treatment to that, which can amount to a few million over the years in rare cases. Most people (the ones that walked away) would be fairly compensated with a few 1000s for damage to their luggage, hotel costs and spoiled holidays...
Dutch judges are sane, so those lawyers went venue shopping in the US.
no sorry *noises from the bathroom*
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Call me old fashioned. " You're old fashioned Ken!".but......
I like to hand fly the a/c when it is near the ground.
That way, I know pretty much exactly what is going on. The a/c has all sorts of ways to protect me when I hand fly, so all I got to do is follow the FD, or if I can see, proceed to land and all will be well.
Of course, the AP could prolly do it better, but hey, at least I know. I KNOW. What is happening
Sometimes we got to to an autoland. Gives me the willies!
I'm no perfect pilot. But.......
I'm always happiest when poling the 'plane.
I like to hand fly the a/c when it is near the ground.
That way, I know pretty much exactly what is going on. The a/c has all sorts of ways to protect me when I hand fly, so all I got to do is follow the FD, or if I can see, proceed to land and all will be well.
Of course, the AP could prolly do it better, but hey, at least I know. I KNOW. What is happening
Sometimes we got to to an autoland. Gives me the willies!
I'm no perfect pilot. But.......
I'm always happiest when poling the 'plane.
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NOS Nieuws - Rapport Turkish Airlines-crash op 6 mei gepresenteerd
Report will be officially released on May 6th
Report will be officially released on May 6th
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It is 2 months later because they have to negotiate (with Turkish Airlines, ATC and Boeing)...
To me a report should be independent to be absolutely sure about what has happend. Negotiations should not be part of it!
To me a report should be independent to be absolutely sure about what has happend. Negotiations should not be part of it!
Cornelis - I am totally with you. TOTALLY. Simply put those pilots, or the one in the left seat, could not manage their speed with an auto throttle failure. Those Dutch lawyers should be going after Turkish Airlines - but Boeing is probably an easier target - as going after Turkish is really taking on a government. A complete farce!