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Turkish airliner crashes at Schiphol

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Turkish airliner crashes at Schiphol

Old 8th May 2010, 18:38
  #2741 (permalink)  
 
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What's that all about?

The crew goofed up the approach.

Sorry to say, but it's that simple.
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Old 8th May 2010, 23:35
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CptCaveman,

Your location says Istanbul, but you obviously don't know what you are talking about.

The F/O was NOT an ex Air Force guy. He was a new hire, still in training.
The other 2 pilots (Captain and the Line Check Airman) were ex Air Force pilots. One was an F16, the other F4 pilot with great reputation for safety.

The message I get from this accident is; If this can happen to those experienced pilots, it can happen to me. So I should NOT spread rumors, look only at the FACTS, and decide for myself how to avoid a similar situation.

Referring to those of you sit behind your keyboards, and type how they screwed up should think carefully before typing...

Very frustrating to see "fellow" pilots posting messages here, acting like ambulance chasing lawyers or newspaper reporters with absolutely nothing to do with aviation.
This thread, Air France thread, all the same..

Am I the only one who feels this way???
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Old 9th May 2010, 00:58
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767Capt

Perhaps the issue is distraction.

There were two or more simultaneous missions underway; the FIRST should have been flying the sector safely. The line check was secondary, and the #1 RA threw more distraction into the cockpit, probably compounded by the extra crew.

The FACTS are - whatever the background and flying record of the crewmen, and whatever the autothrottle problem (including RA), allowing T/L's to remain at idle for 100 seconds in approach configuration with energy rapidly decaying, simply tells me that nobody was minding the store.
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Old 9th May 2010, 02:23
  #2744 (permalink)  
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767Capt;
Very frustrating to see "fellow" pilots posting messages here, acting like ambulance chasing lawyers or newspaper reporters with absolutely nothing to do with aviation.
This thread, Air France thread, all the same..
If that's all you see then I submit that you're not reading either thread very thoroughly. Yes, there are a few comments which are pretty blunt and off the mark but there are many more thoughtful contributions from experienced aviators both here and on the AF447 thread. I see no "ambulance chasing" comments among those who fly nor do I see a brashness that ignores the fundamental fact that any one of us could have been that crew.

What I do see then is puzzlement and an earnest search for a reasonable, rational explanation for why three of our colleagues stalled their airplane when nobody, even the safety pilot who's job it was to notice such things precisely because the guys up front may indeed become inadvertently distracted by the training regime, noticed how far the speed had bled off.

How many of us have had a serious, unexpected incident? Have each one of us who do airline transport work not been there at some point in our careers and not made headlines but learned that we are not invincible?

As for those who make blunt comments, examine them and decide if that's just bluntness or is it something meaner? If so, don't read the poster's work anymore and turn to what you believe is from earnest professionals.
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Old 9th May 2010, 16:19
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Better airmanship MAY have avoided this accident but a serviceable RA WOULD have avoided this accident.
No, a serviceable RA may have just delayed this crew's accident to another day, another situation.

Radio Altimeters, ILS receivers, and IRUs, being part of a Cat III autioland system, are thoroughly analyzed for safety such that an annunciated failure is acceptable; an unannunciated failure is not acceptable. The RA is a simple sensor that outputs what it detects, and it does a fine job of that. It, however, is unable to detect the difference between a valid ground return and leakage between its antennas, due to corrosion or other factors. That falls into the area of Undetected Failures at a system level, a big no-no.

The autopilot and flight director computers receive inputs from both or all three radio altimeters, and compare to decide if there is a fault. The fail warn output of each sensor make it easy most of the time, and the 737 autothrottle computer looks no further, so does not compare values from RadAlts, but merely uses #1 until it puts out Fail Warn.

A pilot, who could see the #1 RadAlt error, could have disengaged the circuit breaker on the #1 RadAlt as soon as it occurred (high on the approach or before), and would have avoided misleading the A/T computer, the GPWS, the pilot during final approach, and probably other devices.

I don't care what your SOPs are with regards to disengaging CBs, I'm merely stating a fact. Too many of you don't remember the early days of EFIS and FMS, where resetting a Circuit Breaker was a usual means to reboot a wayward system.

GB
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Old 9th May 2010, 16:49
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P2J,

I was referring to those "Blunt and off the mark"comments, specifically replying to Captcaveman who posted incorrect information regarding the flight crew.

God forbid if you , me or anyone else has to go through a similar situation, and after they die, "fellow pilots" posting incorrect information is disrespectful in my opinion. Especially if you personally knew any of these pilots as I did.

If you re-read my message, you'll see that I encouraged for us to look only at the facts, learn from their mistakes (only after the facts are known) and not post incorrect info.
That doesn't serve any purpose.

As for your suggestion that I should not read their post and only read posts from earnest professionals; I don't know who those people are. So I kind of have to read them all.

It would be better if all pay attention to what we post, again, these aviators ARE NO LONGER with us, and they have no way to explain what really took place.

Best.
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Old 9th May 2010, 17:30
  #2747 (permalink)  
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767Capt;

Understand; we're on the same page...

best as well. PJ2
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Old 9th May 2010, 19:28
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[QUOTE]No, a serviceable RA may have just delayed this crew's accident to another day, another situation [QUOTE]

Bit harsh. Humans are fallible not perfect. We have take off warning systems for example because crews do overlook the small issue of setting the flaps or ensuring all the doors are closed or whatever. Its not ideal but its human behaviour. It doesn't reflect on professionalism at all, it can happen to anyone and often does, you just get away with it because the holes in the cheese on that particular day didn't line up.

All we can do is try our best to ensure the holes in the cheese don't line up. In utopia we don't mistakes, here on earth we do. Knowing that to be an undisputable fact, why would you accept anything less than an aircraft that is serviceable or has all known defects under control by proper use of the MEL.

The accident report says two previous crews noticed the RA fault and decided not to log it. A third crew were unaware of the defect, lost situational awareness for whatever reason and paid for it with their lives.

I cannot tell where the crew were on the scale of professionalism because I wasn't there but just as in the Spanair tragedy, not dealing with a defect has costs lives. The holes in the cheese lined up.

Go on about airmanship as much as you want, even the best crews will one day have an off day. I hope when that day arrives all your onboard systems are working as advertised or have been deferred correctly.
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Old 9th May 2010, 20:05
  #2749 (permalink)  
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767 captain : I do not quite follow your reasoning.

Captcaveman mentioned the fact that the F/O was ex-air force and you categorically said he was not and argue we should not denigrate the guys and pass incorrect info.
But in fact the Dutch report says page 9 :
The first officer had moved from the Turkish Air Force to Turkish Airlines in June 2008. He hadgained about 4000 hours of flight experience in the air force. For the first officer, the flight was part of a training ‘line flying under supervision’. It was his 17th line flight under supervision and his first
flight to Schiphol airport.
Later in the report said he had 44h on type.
The Safety pilot is reported there to have 720h on type and was 28 years old.
The capt was repported to be 54 years old with nearly 11.000 h on type.

Are you saying that info is incorrect ?

I know also a bit Turkey, and the report info is correct, I am, for one encline to believe that in this combination, nobody in that cockpit was going to question the Capt taking over and actions thereafter.
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Old 9th May 2010, 20:33
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@ Barit1

Quote: Perhaps the issue is distraction.

There were two or more simultaneous missions underway; the FIRST should have been flying the sector safely. The line check was secondary, and the #1 RA threw more distraction into the cockpit, probably compounded by the extra crew.

The FACTS are - whatever the background and flying record of the crewmen, and whatever the autothrottle problem (including RA), allowing T/L's to remain at idle for 100 seconds in approach configuration with energy rapidly decaying, simply tells me that nobody was minding the store. unquote

I'm sorry but I find your comment extremely...well for a loss of words...dumb

If you read the report you will find that notwithstanding the faulty retard mode the thrust would have been at idle anyways due to the fact that they were descending from above the glideslope and trying to decelarate at the same time. The thrust was only improperly at idle for about 25s after they reached FAS at about 700 feet. One of the reasons given that they didn't notice the autothrottle advancing and maintaining FAS was that they were probably distracted by performing the landing C/L.

Yes, they should have made a go around according to THY procedures and international established procedures, no question. I wonder though, how many on this board have dipped (just ever so slightly) below the stabilised approach criteria at any one time??? Be honest now!!!

Please read the report before commenting

Last edited by flyburg; 9th May 2010 at 20:45.
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Old 9th May 2010, 20:33
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Assuming that our industry has achieved the status of ‘a highly reliable (ultra-safe) system’, we should use alternative analyses of accidents to identify solutions.
Highly reliable systems are complex and lack predictability and thus may not respond to conventional methods of control – fixing safety problems.

Many posts, including those ‘blunt and off the mark’ comments use mechanistic thinking. This is based on ‘evidence’; it assumes that facts from one context applies in another (tech failures vs human failures), it assumes a linear relationship between cause and effect, and often results in statistical based solutions. Mix these together with weak understanding or failure / inability / reluctance to consider the human element, often results in biased viewpoints.

We must take wide ranging and alternative views. Consider the many contributions in this accident how they might link or interact with each other and modern flight operations. It is unlikely that we will be able to determine a precise outcome – neither the problems nor solutions, because the very nature of complexity prevents us from forecasting the result of safety activities.

By considering the contributing factors, links, and interactions, we can generate a framework for action – something to hang future safety improvements on. We might seek to improve / eliminate all of the contributions factors as no one issue can be proven to prevent future events, the analogy is adding cladding to the frame work and thereby strengthening the structure – safety.
However, this might be a weakness in thinking, often leading to a trade off between safety and economics – one or the other. This requires an alternative view – a culture where safety and economic prosperity is developed jointly.

A complementary and very important aspect is to reconsider the many assumptions associated with the contributing factors.
The manufacturing and regulatory processes make assumptions about equipment reliability and warning system effectiveness; operationally the industry holds many assumptions about human performance – pilot and ATC, context dependent.
The industry (top-down and bottom-up) should re-evaluate these assumptions; are they still valid, has the operating environment changed, are ‘old aircraft’ designs applicable to new pilot training, and is the pilot (human performance / capability) changing – adapting, or failing to adapt to a new operating environment (all the arms of the SHEL model).

Much of the above was influenced by Systems Thinking – “it enables people to see a bigger picture that makes more sense of their world”.
At least read the preface and summary; read them again in the context of aviation safety, and then again relating the issues to this accident.

“… difficulties are bounded problems, and individuals will know when they have found the solution. … with a mess there is rarely agreement about where the problem actually lies or where improvements can best be made, and they are subject to high levels of uncertainty.
Another difference between these classes of problem is that when the problem is a difficulty an individual claiming to have the solution is an asset, but when the problem is a mess that individual is usually a large part of the problem!”

Also see Revisiting safety and human factors paradigms to meet the safety challenges of ultra complex and safe systems.
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Old 9th May 2010, 21:20
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flyburg:

My statement was certainly incomplete, and I'm sorry you find it dumb.

I think most human factors engineers would agree that the human animal doesn't do a great job of monitoring a closed-loop system (e.g. autothrottle), particularly in a busy/distracting environment. The transition from "above-GS" to GS capture is effectively a system mode change that the A/T and the crew both missed.

If the system design leaves the human out-of-loop, then mode changes should be automatically announced to recapture the pilot's attention to focus on monitoring.

But that doesn't excuse what happened. I see this accident bears a remarkable resemblance to DCA73AZ005, EAL401, where again no one was minding the store.
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Old 9th May 2010, 21:54
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Hello Barit1,

My response was certainly worded harsly and reading your response maybe too harsly.

In regards to your last response, yes, humans are excellent performers but bad monitors. The report actually mentions this. It even makes a remark about AP annunciations and how most pilots ( all airlines to do not monitor them carefully)

Please read the report, I won't say this wouldn't happen to me. I you read carefully all the holes in the swiss cheese lined up perfectly that day. Next day they might not have. Your reference to EAL. Excellent, think of the Tenerife accident, just a small mistake, Taking off without clearance. Has happened many times (really) just this day,somebody happened to be on that runway.

Anyways, learn the lessons and apply them
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Old 9th May 2010, 23:33
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ATC Weather,

It can be confusing to people that are not familiar to the THY system. I hope someone who works there can better explain than I, but I will try:

There were 3 pilots in the cockpit; 2 of them (Captain Hasan Tahsin Arisan and the Safety Pilot, F/O Murat Sezer) were former Air Force (one F16, the other F4) pilots, F/O in training was Olgay Özgür. He was NOT former Air Force or any branch of the military. (His father was a Retired Army pilot)

F/O Özgür was 29 years old and graduated from Ankara University- Geology dept in 2005, then got his Commercial Pilots license (#4554), worked for World Focus Airlines, then got hired by THY on 11 April 2006.

If you understand Turkish, here is the newspaper article about F/O Olgay Özgür:

Babası Emekli Karacı Pilot Albay olan Özgür, küçük yaşlardan itibaren havacıkla ilgiliydi. 29 yaşındaki Özgür, Ankara Üniversitesi Jeoloji Mühendisliği’ni 2005’te bitirdi.

29 yaşında 2. pilot

Üniversite eğitimi sırasında Ankara Esenboğa’da bulunan Sindel Havacılık’ta pilotaj eğitimine başladı. 2005’te 4554 numaralı Ticari Pilot Lisansını aldı. Olgay Özgür, ilk olarak Isparta’da 2007’de uçağı düşen World Focus Havayolları’nda göreve başladı. Burada MD83 tipi uçakta 450 saat uçuş gerçekleştirildi.

World Focus Havayolları’ndan sonra 11 Nisan 2006’da Türk Hava Yolları’na geçti. Boeing 737-400 ve 800 uçak tiplerinde eğitim gördü. Evli olan Özgür, THY’de kıdemli ikinci pilot olarak uçuyordu. İngilizce bilen İkinci Pilot Özgür’ün toplam uçuş saati 3 bindi.

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Old 9th May 2010, 23:48
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Alf507h,

Thank you for the very informative and interesting post.

Digging a bit deeper, I found the following sentence very thought provoking in your link:
"In System Failure I argue that the dominant approach to policymaking was based on mechanistic and reductionist thinking."

C/L/R (or C/R/M) is one of my interest areas as well. It works. After the 1978 United Airlines accident, UAL started their industry leading C/L/R program to prevent another accident from happening ever again, and there has not been a single loss of life as a result of Pilot Error at United since!

You gave me something to research for the next couple hours.. (Wife is not too happy- on Mother's Day)

Best.
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Old 10th May 2010, 07:59
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Originally Posted by 767Capt
There were 3 pilots in the cockpit; 2 of them (Captain Hasan Tahsin Arisan and the Safety Pilot, F/O Murat Sezer) were former Air Force (one F16, the other F4) pilots, F/O in training was Olgay Özgür. He was NOT former Air Force or any branch of the military. (His father was a Retired Army pilot)

F/O Özgür was 29 years old and graduated from Ankara University- Geology dept in 2005, then got his Commercial Pilots license (#4554), worked for World Focus Airlines, then got hired by THY on 11 April 2006.
Wait a minute. That's not what the official report says. It says the F/O in training was the 42 yr old ex air-force guy and the safety pilot was the 28 yr old guy. (ref: English report pages 9, 181 and 182) I think you might be confusing things. I can't read Turkish but I would never thrust any newspaper article over an official report in aviation matters.

Either you or the official report are making a mistake, and since the draft report has been reviewed by all parties involved, I tend to believe you are the one making the mistake.

Best regards,
Sabenaboy
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Old 10th May 2010, 08:52
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767Capt ,I fully agree with Sabenaboy , I think you maight be confused by the newspaper articles ( I cannot read Turkish either, sorry ) as to who was the acting F/O PF and who was the safety pilot on this flight.

According the report , The F/O PF is the 42 years old one with 44h on type and 4000 h in the airforce that pushed the throttles forward after stick shaker activation, and the safety one on the jump seat was the 28 ( or 29) years old one.
On this configuration,when the Capt instructor took over, the 2 others were , in my opinion and knowing a bit Turkey very uniquely to question the Capt actions.
Correct me if I am wrong.
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Old 12th May 2010, 01:56
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Capt. Caveman,
I would like to apologize to you for MY incorrect statement. I was wrong in stating that the F/O was not ex military, he was..
It was the Safety Pilot who was the younger pilot and was from civilian sources.
They carry 3 pilots, and I made the mistake of assuming the younger guy was the one sitting in the right seat.
My apologies again.
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Old 12th May 2010, 01:59
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Sabena Boy and ATC Watcher,

I stand corrected, please see my apology post to Capt Caveman.

Thanks for correcting me.

BTW: do either of you have the link (English please) for the full final report?

Thanks.
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Old 12th May 2010, 06:36
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http://www.onderzoeksraad.nl/docs/ra...TA_ENG_web.pdf
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