Turkish airliner crashes at Schiphol
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What report from which host? 
The final report can still be found at the dutch safety board!
Take a look here:
Crashed during approach, Boeing 737-800, Amsterdam Schiphol AIrport - De Onderzoeksraad voor veiligheid
The final report can still be found at the dutch safety board!
Take a look here:
Crashed during approach, Boeing 737-800, Amsterdam Schiphol AIrport - De Onderzoeksraad voor veiligheid
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I meant this one. Sorry for misunderstanding.
"Here's the TK1951 Human Factors Report, written by Sidney Dekker for the Dutch Safety Board. Very interesting!"
"Here's the TK1951 Human Factors Report, written by Sidney Dekker for the Dutch Safety Board. Very interesting!"
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I read the report, and made notes. It lacked. Nowhere did the author distinguish between the gravity of an annunciated failure, and an undetected error, which was the case with the radalt.
Engineers designing Cat III autoland systems go to great lengths to assure there are no undetected failures that could kill people in umpteen fleet lifetimes. Annunciated errors and failures are expected and accommodated by the airplane systems.
If you look at this accident, and others, with annunciated vs. undetected failures in mind, the shading is quite different.
Engineers designing Cat III autoland systems go to great lengths to assure there are no undetected failures that could kill people in umpteen fleet lifetimes. Annunciated errors and failures are expected and accommodated by the airplane systems.
If you look at this accident, and others, with annunciated vs. undetected failures in mind, the shading is quite different.
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Granted that humans are known to do a better job when "in the loop" than when monitoring another human, or monitoring the automation...
But when capturing the glideslope, whether from below or above, shouldn't ONE pair of eyes observe and confirm actual capture (track, power, airspeed)? To me it's as elementary as confirming flaps or gear.
But when capturing the glideslope, whether from below or above, shouldn't ONE pair of eyes observe and confirm actual capture (track, power, airspeed)? To me it's as elementary as confirming flaps or gear.
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I started to refuse ATC instructions after many screw ups on the line. These people bring you in too fast, too close to the airport, and sometimes too high. The electronics can not capture a glide slope from above, and the ACT approach controllers should be aware of that limitation. Pilots have to learn to say "NO" to these people when they screw up. Far better to extend the downwind leg than to try to salvage poor vectoring and end up dead.
A quick calculation one can do (if above the GS) is to add one to the ground speed for the rate of descent i.e. GS 150 kts, add one to the 15 and that becomes 1600 FPM. This gives you a 6 degree slope to capture the 3 degree glide slope. So: 140 = 1500, 150=1600, 160=1700 etc. Do NOT exceed 2000 fpm. Don't let them fly your airplane. That's not their job. Their job is to separate little dots on the screen.
A quick calculation one can do (if above the GS) is to add one to the ground speed for the rate of descent i.e. GS 150 kts, add one to the 15 and that becomes 1600 FPM. This gives you a 6 degree slope to capture the 3 degree glide slope. So: 140 = 1500, 150=1600, 160=1700 etc. Do NOT exceed 2000 fpm. Don't let them fly your airplane. That's not their job. Their job is to separate little dots on the screen.
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ATC do this because they unaware of the limitations of your aircraft and what you operationally need and want.
Sadly communication meetings between active line pilots and active ATC controllers are a thing of the past...everyone works flat out these days and under pressure and are trying to fit a quart into a pint pot and as rapidly as possible.
I do not blame you for flying very much with your guard up and sometimes refusing being suckered into a bad situation...this is old fashioned airman-ship and pilot in command responsibility...it also keeps your sorry bottom out of the non flying chief pilots office on your day off.
Sadly communication meetings between active line pilots and active ATC controllers are a thing of the past...everyone works flat out these days and under pressure and are trying to fit a quart into a pint pot and as rapidly as possible.
I do not blame you for flying very much with your guard up and sometimes refusing being suckered into a bad situation...this is old fashioned airman-ship and pilot in command responsibility...it also keeps your sorry bottom out of the non flying chief pilots office on your day off.
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Cockpit crisis
In five years, over 50 commercial airplanes crashed in loss-of-control accidents. What’s going on?
With low clouds and a fine mist hanging in the morning air, the pilots of Turkish Airlines Flight 1951 anticipated a routine approach to Amsterdam’s busy Schiphol Airport on Feb. 25, 2009. But instead of touching down gently on the runway, the white and red Boeing 737 dropped out of the sky and slammed into a muddy field just short of the airport, smashing into three pieces. Nine people died, including all three pilots. Another 84 were injured.
Investigators attributed the crash to a faulty radio altimeter, aggravated by pilot errors and oversights. Radio altimeters use radio waves to measure a plane’s altitude—a key piece of equipment, which is why a 737 is equipped with two of them. But what nobody in the cockpit of Flight 1951 realized was that the malfunctioning altimeter happened to control the 737’s auto-thrust systems. So while the co-pilot was busy monitoring the autopilot (which used data from a different altimeter), and Capt. Hasan Tahsin Arisan was watching the co-pilot as part of a training exercise, and a third “safety” officer was supposed to be watching everyone to make sure nothing got missed, the auto-thrust erroneously engaged its “retard” mode, thinking it was just above the runway. The throttles were cut and the plane’s nose pitched up, causing the plane to drift into an aerodynamic stall. The flight crew tried to recover by returning the throttles to full power, but their initial efforts were thwarted by the confused auto-thrust system, which they forgot to disengage. There was no time for a second try.
Statistically speaking, modern avionics have made flying safer than ever. But the crash of Flight 1951 is just one of several recent, high-profile reminders that minor problems can quickly snowball into horrific disasters when pilots don’t understand the increasingly complex systems in the cockpit, or don’t use them properly. The point was hammered home later that year when Air France Flight 447 stalled at nearly 38,000 feet and ended up crashing into the Atlantic, killing all 228 on board. Investigators recently released transcripts from the Airbus A330’s cockpit voice recorder. It reveals a flight crew gripped by confusion as they tried to diagnose and respond to what should have been a manageable mid-air emergency, but instead resulted in a terrifying 3½-minute plunge in total darkness. “I don’t have control of the airplane anymore,” the co-pilot at the controls said at one point. “Now I don’t have control of the airplane at all.”..........more at link below
Cockpit crisis - World - Macleans.ca
In five years, over 50 commercial airplanes crashed in loss-of-control accidents. What’s going on?
With low clouds and a fine mist hanging in the morning air, the pilots of Turkish Airlines Flight 1951 anticipated a routine approach to Amsterdam’s busy Schiphol Airport on Feb. 25, 2009. But instead of touching down gently on the runway, the white and red Boeing 737 dropped out of the sky and slammed into a muddy field just short of the airport, smashing into three pieces. Nine people died, including all three pilots. Another 84 were injured.
Investigators attributed the crash to a faulty radio altimeter, aggravated by pilot errors and oversights. Radio altimeters use radio waves to measure a plane’s altitude—a key piece of equipment, which is why a 737 is equipped with two of them. But what nobody in the cockpit of Flight 1951 realized was that the malfunctioning altimeter happened to control the 737’s auto-thrust systems. So while the co-pilot was busy monitoring the autopilot (which used data from a different altimeter), and Capt. Hasan Tahsin Arisan was watching the co-pilot as part of a training exercise, and a third “safety” officer was supposed to be watching everyone to make sure nothing got missed, the auto-thrust erroneously engaged its “retard” mode, thinking it was just above the runway. The throttles were cut and the plane’s nose pitched up, causing the plane to drift into an aerodynamic stall. The flight crew tried to recover by returning the throttles to full power, but their initial efforts were thwarted by the confused auto-thrust system, which they forgot to disengage. There was no time for a second try.
Statistically speaking, modern avionics have made flying safer than ever. But the crash of Flight 1951 is just one of several recent, high-profile reminders that minor problems can quickly snowball into horrific disasters when pilots don’t understand the increasingly complex systems in the cockpit, or don’t use them properly. The point was hammered home later that year when Air France Flight 447 stalled at nearly 38,000 feet and ended up crashing into the Atlantic, killing all 228 on board. Investigators recently released transcripts from the Airbus A330’s cockpit voice recorder. It reveals a flight crew gripped by confusion as they tried to diagnose and respond to what should have been a manageable mid-air emergency, but instead resulted in a terrifying 3½-minute plunge in total darkness. “I don’t have control of the airplane anymore,” the co-pilot at the controls said at one point. “Now I don’t have control of the airplane at all.”..........more at link below
Cockpit crisis - World - Macleans.ca
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Altimeter of Boeing 737 was repaired 16 times
Today some news on the Turkish Airlines Boeing 737 crash on short final at Schiphol airport in 2009
google translation used.
Article - Luchtvaartnieuws
THE HAGUE - The altimeter of the Boeing 737-800 Turkish Airlines on February 25, 2009 crash at Schiphol was in the period from January 2008 to February 2009, 16 malfunctioned. That said Wilma Mansveld Secretary for Infrastructure Monday to questions from Labour MP Attje Kuiken.
It is not true, writes the Secretary, that the defects are not repaired. "In all cases, action such as restarting the system and replacing the antenna,'' she wrote to the House.
The Turkish Airlines Boeing 737 had 135 people aboard. The plane crashed 25 February 2009 during the landing down to a field near Schiphol. Nine people were killed and 120 others were injured.
The Public Prosecutor (OM) decided in April last year, no criminal prosecution because of the accident. The prosecution examined whether someone had done something criminal perch in the crash. This was the case for the pilots, Boeing and the air traffic control.
On the role of the pilots important information is missing in the study because they are deceased and therefore could no longer be heard, said the OM then. The technical problem with the altimeter of the Boeing was known to the pilots, who had to solve. It was not a safety problem.
google translation used.
Article - Luchtvaartnieuws
THE HAGUE - The altimeter of the Boeing 737-800 Turkish Airlines on February 25, 2009 crash at Schiphol was in the period from January 2008 to February 2009, 16 malfunctioned. That said Wilma Mansveld Secretary for Infrastructure Monday to questions from Labour MP Attje Kuiken.
It is not true, writes the Secretary, that the defects are not repaired. "In all cases, action such as restarting the system and replacing the antenna,'' she wrote to the House.
The Turkish Airlines Boeing 737 had 135 people aboard. The plane crashed 25 February 2009 during the landing down to a field near Schiphol. Nine people were killed and 120 others were injured.
The Public Prosecutor (OM) decided in April last year, no criminal prosecution because of the accident. The prosecution examined whether someone had done something criminal perch in the crash. This was the case for the pilots, Boeing and the air traffic control.
On the role of the pilots important information is missing in the study because they are deceased and therefore could no longer be heard, said the OM then. The technical problem with the altimeter of the Boeing was known to the pilots, who had to solve. It was not a safety problem.
But the crash of Flight 1951 is just one of several recent, high-profile reminders that minor problems can quickly snowball into horrific disasters when pilots don’t understand the increasingly complex systems in the cockpit, or don’t use them properly.
More a question of pilots not being trained and/or practised in the basics of flight control.
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@fireflybob
Do you agree, about several examples of incidents/accidents at well known carriers besides THY, like AF/LH/TAM and others, where the crew lost track due to "complexity" of their ship?
Do you agree, about several examples of incidents/accidents at well known carriers besides THY, like AF/LH/TAM and others, where the crew lost track due to "complexity" of their ship?
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Okay, and I agree about adequate pilots training !
Some airlines are doing that, others don't.
And there is a change in manufactores philosophy, even at Airbus...
"Don't touch anything"
"Fully automatique"
"All by Puesh buetton"
Now, they know different.
Payed with blood!
Some airlines are doing that, others don't.
And there is a change in manufactores philosophy, even at Airbus...
"Don't touch anything"
"Fully automatique"
"All by Puesh buetton"
Now, they know different.
Payed with blood!
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"Do you agree, about several examples of incidents/accidents at well known carriers besides THY, like AF/LH/TAM and others, where the crew lost track due to "complexity" of their ship?"
I disagree, slightly. I am giving a Type qualification course at the moment. As with many airlines it is self-funded by the student and thus is kept to a minimum number of sessions. As with other airlines the type rating is combined with an OPC. A few decades ago, in my early life entering the airlines, we were taught to fly the a/c in the TQ course, with SOP's attached. The line operation and SOP's were refined during line training. The initial emphasis was knowing how the a/c worked, how the systems worked and how to fly it. The line training refined these skills and expanded how to operate it within the airways system and a multitude of busy airports and small visual airfields. Understanding the complexities of the systems came with our 'apprenticeship', which had started in the sim.
Nowadays the TQ course seems to shift the emphasis more towards SOP's during the manoeuvres, some of which are with normal & non-normal scenarios. Some of the non-normals scenarios are box-ticking on the LST form, very few are in depth training of the gotchas and pitfalls. The handling emphasis is aimed at the LST items.
Thus IMHO it was not the 'complexity of their ship' which sucked them into trouble, it was the lack of training = understanding of those systems. This ignorance created a complex system when in fact with proper training it would have been quite simple.
One wonders if the policy of many airlines to use relatively (2 years experience) inexperienced F/O's as SFI's is correct. They have followed the self same course of knowing what to do, but not the how & the why. They then pass on this diluted knowledge to the next generation of cadets who will become the next generation of SFI's and so the downward spiral of knowledge continues. SOP's are so intense that the first thought of a pilot in a less than ideal situation is to ask, "what does the book say?" Second, if at all, comes "what is the most sensible airmanship thing to do?" By the time you arrive at the 2nd option it might be too ate as the a/c was still travelling very fast during the first phase of questioning confusion. It is noticeable that I've been told by newish F/O's that flying with the old farts is usually more relaxing than with the newbie captains. The oldies do what is best instinctively, and within the book boundaries, but are not afraid to bend the SOP's; the newbies are terrified to even blow at the boundaries and thus delay making some decisions and then have to race to catch up. All old farts were newbies once, but mostly with a longer and deeper apprenticeship than today.
IMHO, if the industry is gong to continue making captains with relatively low hours then the training of manual skills, and especially systems knowledge and understanding of all their possibilities, needs to be more in depth to compensate for the shorter apprenticeship. Too many commands can be given to those whose prof checks are above average and SOP knowledge is perfect. SOP's can not cover all eventualities. Most incidents and accidents started quite subtly and the human intervention, or lack of it, caused a can of worms to develop, when it was preventable. And that's a whole other discussion about a good crew being preventative rather than reactive. Slavishly following SOP's is not always preventative, but that was touched upon in an earlier thread.
Knowledge is power: ignorance can be painful in the extreme.
I disagree, slightly. I am giving a Type qualification course at the moment. As with many airlines it is self-funded by the student and thus is kept to a minimum number of sessions. As with other airlines the type rating is combined with an OPC. A few decades ago, in my early life entering the airlines, we were taught to fly the a/c in the TQ course, with SOP's attached. The line operation and SOP's were refined during line training. The initial emphasis was knowing how the a/c worked, how the systems worked and how to fly it. The line training refined these skills and expanded how to operate it within the airways system and a multitude of busy airports and small visual airfields. Understanding the complexities of the systems came with our 'apprenticeship', which had started in the sim.
Nowadays the TQ course seems to shift the emphasis more towards SOP's during the manoeuvres, some of which are with normal & non-normal scenarios. Some of the non-normals scenarios are box-ticking on the LST form, very few are in depth training of the gotchas and pitfalls. The handling emphasis is aimed at the LST items.
Thus IMHO it was not the 'complexity of their ship' which sucked them into trouble, it was the lack of training = understanding of those systems. This ignorance created a complex system when in fact with proper training it would have been quite simple.
One wonders if the policy of many airlines to use relatively (2 years experience) inexperienced F/O's as SFI's is correct. They have followed the self same course of knowing what to do, but not the how & the why. They then pass on this diluted knowledge to the next generation of cadets who will become the next generation of SFI's and so the downward spiral of knowledge continues. SOP's are so intense that the first thought of a pilot in a less than ideal situation is to ask, "what does the book say?" Second, if at all, comes "what is the most sensible airmanship thing to do?" By the time you arrive at the 2nd option it might be too ate as the a/c was still travelling very fast during the first phase of questioning confusion. It is noticeable that I've been told by newish F/O's that flying with the old farts is usually more relaxing than with the newbie captains. The oldies do what is best instinctively, and within the book boundaries, but are not afraid to bend the SOP's; the newbies are terrified to even blow at the boundaries and thus delay making some decisions and then have to race to catch up. All old farts were newbies once, but mostly with a longer and deeper apprenticeship than today.
IMHO, if the industry is gong to continue making captains with relatively low hours then the training of manual skills, and especially systems knowledge and understanding of all their possibilities, needs to be more in depth to compensate for the shorter apprenticeship. Too many commands can be given to those whose prof checks are above average and SOP knowledge is perfect. SOP's can not cover all eventualities. Most incidents and accidents started quite subtly and the human intervention, or lack of it, caused a can of worms to develop, when it was preventable. And that's a whole other discussion about a good crew being preventative rather than reactive. Slavishly following SOP's is not always preventative, but that was touched upon in an earlier thread.
Knowledge is power: ignorance can be painful in the extreme.
Last edited by RAT 5; 15th Jan 2013 at 13:40.
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Not sure about the 'LH' quoted, but all the others were accidents which SHOULD have been avoided by BASIC flying skills. Why they were not exercised is a discussion point. There was certainly enough 'experience' in the three examples to have avoided the crashes. Was it that over-reliance on the 'systems' (aka 'complexity') caused the lack of attention to the basics?