Turkish airliner crashes at Schiphol

[Oakape]

It seems to me that some have forgotton that this was a training flight. Seems a stupid statement, but bear with me.

The F/O in the right seat must have been very new to the operation. Safety pilots are usually only used for the first 6 - 8 sectors. Those who have trained will know just how high the workload is for a training captain in the very early stages. You are effectively doing both roles - PF & PNF. If the trainee is flying a sector, you have to perform the PNF functions and also do your best to follow everything the trainee is doing, comparing it to what you know should be happening & ensuring that things are staying on track. During a busy approach this can get to the stage of overload. Often things get missed while you are answering a radio call or running a checklist. If you have to correct something the trainee has done wrong, other developing issues can be missed as well. This situation will generally improve as the trainee gains experience.

That is why you have a safety F/O in the early stages. It is his/her role to monitor the basics & ensure that the operation stays safe. However, not all airlines train their F/O's for this role & I would say that some are not even suited for the role. It has been my experience that the role is often not taken as seriously as it should be by management & pilots alike. When things get busy, some safety F/O's can be drawn into what is going on at the time & forget to keep monitoring the basics. Also, on the 737, it can be difficult to adequately monitor the flight instruments from the jump seat. The Capt's PFD can be hard to see at times, particularly the left side where the ASI is displayed. The F/O's PFD is generally more visible, however it can be partially blocked by the control column & the F/O's body.

It's a judgement call, but sometimes it is better for a training captain to just take over when the workload becomes too high. Most are loathe to do it, as they don't want the trainee to have their confidence dented. They also want the trainee to gain experience.

Maybe that was the case here. The captain was getting overloaded with the situation & just missed the airspeed. The safety F/O may have been too involved with the situation & forgot to step back & monitor the basics. It happens.

Not having been able to sit behind these guys & objectively watch them operate, we don't really know if they were incompetent or were just caught out be they circumstances on the day. It is all just educated (or uneducated) guessing & speculation.

[DozyWannabe]

Originally Posted by Oakape

A generalization I know, but sometimes there seems to be as much misplaced faith in the regulators getting it right...

The regulatory authorities can only act on what they know. Should they be informed of an airline that is using CRM training in lieu of flight and handling training then they would be compelled to act, because if such practices were uncovered and it could be proven they had prior knowledge, then they would be found legally culpable.

Again with the caveat that I am not a line pilot, I personally suspect that there are no such practices at present. Don't get me wrong, there's a lot to be wary of regarding modern airline management and its lack of understanding as to how unique a business aviation is - but the notion that CRM is nothing more than an enforcement of "political correctness" on the flight deck betrays an equally worrying lack of understanding.

[PJ2]

fdr;

I accept your excellent clarifications regarding CRM as wise, within the context of present understandings of CRM. Some dismissed CRM as a course in courtesy, diplomacy and a leveling of the command-and-control process in modern cockpits.

Of course this is not what CRM is. Nor, as you point out, is CRM a "crew - cooperation" program - the cockpit is NOT a democracy! - somebody, (the captain) is required to make the decision.

CRM was a way of arriving at that decision so that all information available from all crew members in the cockpit is available, in a timely fashion, so that a decision, sometimes even a unilateral one by the captain though "buy-in" is always a goal, can be made, resolving the problem.

As you observe, CRM is nothing new to those who already knew how to communicate and fly, at the same time...

What has been forgotten by those who dismiss CRM or mistake it for what Haynes, Sully et al. all did are the origins of the need for "CRM".

CRM was originally a solution to the era during the 60's, 70's & even the 80's where, the "captain is god", the corollary being, 'god makes no mistakes.' The perception and sometimes even the reality was, if the F/O, the S/O, the F/E or the NAV raised a question, offered a suggestion or even directly challenged the captain, it was seen as "attempting to take over the airplane" or questioning the captain's authority. With some of the crustier guys (from WWII), one risked having one's head bit off.

CRM arose also from the opposite behaviour - no one was in command and therefore mission-critical decisions were either not made, or not made in time to save the operation. The UAL DC8 fuel-exhaustion accident at Portland, the classic, classroom example, where the flight's fuel situation was never managed to the point of resolution. Though other circumstances obtained, the Turkish accident has this quality.

There had to be a way to get the "neanderthals" as you use the term, to listen to others because they might actually have something useful to say, like "captain, should we be at this altitude in this area?"

I recall at the time of my CRM course around 1990, that the guys who needed the course most, never "got it" and dismissed CRM as a 'loss of the captain's authority" among other reactions, and those guys remained difficult to fly with, while the guys who understood what CRM was for, did well on the course because they were always that way anyway.

CRM is intended to deflect and otherwise work around those personal qualities which can interfere with and even completely stop communication between crew members in mission-critical, high-risk circumstances where the mere aberrant behaviour of those involved can become single points of failure which may cause the loss of the mission in a perfectly serviceable aircraft. Off the top of my head I can think of well over a dozen and a half major, fatal accidents which fall into this category.

And in this sense it can be argued that the Airblue accident at Islamabad, the AF 447 accident into the Atlantic, the Turkish accident under discussion on this thread and in certain ways the Colgan accident at Buffalo were all, first, profound failures of CRM. There are others.

CRM is something of a mini-intervention, which has been formalized into specific steps which require specific outcomes (resolutions and a plan of action) within a time-frame.

Had the principles of CRM been adhered to by the three crews involved in these accidents, the accident likely would not have occurred.

I agree entirely with the view that CRM had little to do with the outcomes of UA232, US Airways 1549. It was just intelligent, experienced, professional aviators doing their job together, and doing it well.

[DozyWannabe]

Hi PJ2 - apologies for stepping in on the response to fdr, but I'd like to pick your brains while you're here...

Given that:

Originally Posted by PJ2

CRM is nothing new to those who already knew how to communicate and fly, at the same time...

And that

the outcomes of UA232, US Airways 1549 [were] just [a result of] intelligent, experienced, professional aviators doing their job together, and doing it well

Can it not be considered that the aforementioned incidents show what good CRM (as a concept, not as a training regime) should be?

CRM was originally a solution to the era during the 60's, 70's & even the 80's where, the "captain is god", the corollary being, 'god makes no mistakes.' The perception and sometimes even the reality was, if the F/O, the S/O, the F/E or the NAV raised a question, offered a suggestion or even directly challenged the captain, it was seen as "attempting to take over the airplane" or questioning the captain's authority. With some of the crustier guys (from WWII), one risked having one's head bit off.

Agreed, and I also agree with your points regarding the opposite end of the scale. However CRM training - then as now - seems to have come in different "flavours" when implemented by different airlines. As I said before, United's was called CLR - and it eschewed some of the more ephemeral aspects in favour of purely attempting to achieve the best possible result via intelligent use of the crew's abilities.

CRM is something of a mini-intervention, which has been formalized into specific steps which require specific outcomes (resolutions and a plan of action) within a time-frame.

In terms of training (with a focus on remedial action) yes, but the concept at its heart is, as you say, already applied by a lot of pilots without having to recognise and name it as CRM.

A penny for your thoughts?

[fdr]

CLR/CRM etc.


PJ, thanks for taking the time to digest my comments.

Dozy, the human interaction in complex dynamic systems is critical. It was when Orville & Wilbur were doing their first transition from bikes to bipes. The environment has become more complex over time, and the energy levels have increased, but it has always been the case that the Wright Flyer or the J3 Cub can barely kill, but kill they will.

"CRM" is a loose term for human factors, and the focus is generally towards risk management. The early renditions were related to dealing with communications more or less a rehash of signal theory and an awareness of Gert Hofsteade's treatise, thereafter we went towards organisational causation per James Reason, expansion of team dynamics with Dan Maurino, HMI/automation by Asaf Degani & Earl Weiner, and thereafter towards SA, Mica Endsley & Co, Threat and Error Management etc, with additional research from Neil Johnson and Co, Gary Klein NDM, RPDM etc, and other facets of how we, humans work well and not so well with systems, and each other. This is not nearly an exhaustive review... There is a wealth of excellent research and committed individuals and institutions dealing with these vexatious issues across the globe.

My concern is however you package up the training potential that you get from these components of the total issue of human/system interaction (SHEL-SHELL etc if you must) then at the end of the day, it cannot be a replacement for the fundamental skill sets of dealing with an aircraft as a simple physical tool. Being unable to recognise a stall, or recover from a stall is an unacceptable point to have achieved. Having a wonderful interactive & immersive human factors program may reduce your potential exposure to ever getting stalled, but it will not stop the situation occurring. Nor will automation and smart systems, A320/330's etc stall quite well, just needs a dynamic change to exceed the program envelope and you are on your way to a fun ride. Don't even need a system failure, but they apparently happen routinely, (447, Perpignon, HDA 323 etc...). After all is said and done, being able to fly an aircraft remains a core function of being a Captain or FO, otherwise you are merely running a blood lottery.

The industry has elected to proceed down that path. Perhaps if the passengers think this is a great program, cost effective etc, and that the human can be removed from the system or be trained to not have human frailties, then maybe all is well. Doubt the family of 447 or 1549 would agree.

I believe in education and increased self awareness, as it assists in understanding the environment we work in. It is not a replacement for core skills, and that is what is currently killing us. IFLOC is an indictment on the direction the industry has gone, in cost cutting on core competencies. We need both to be functioning, not one replacing the other. Automation and smart systems not only give new issues for the human machine interface, they also give new opportunities for human error to enter in the design phase; it is not a panacea, more akin to a placebo.

to add to the misery of the programs, the assumption that systematic processes will automatically make you safe, or that compliance is an analogue for safety is an issue. Without boring anyone more than I have, SMS is fundamentally flawed, as are existing audit programs in the main. Few operators actually comprehend, or care to implement the functionality of the beautiful systems that are available and often installed gathering dust.

On another forum, an associate has made the pertinent point that the inanity of most safety related rhetoric is tiresome. There is ABSOLUTELY NO ORGANISATION out there that believes that "SAFETY IS OUT FIRST PRIORITY". Absolute marketing BS/hype. May make the regulators happy, and comfort the next of kin, makes no difference to the operators attitude to profit vs safety, has more value for potting plants in... If we are in the business of safety, then there should not be any aircraft or trains, ships operating. We are actually in the business of making a profit first and foremost with the lowest cost attributed to the needs of achieving safety at the level that is palatable by the public, otherwise known (somewhat misleadingly) as ALARP/ALARA.

Life is risky, we should get used to it. I get tired of listening to inanity, as does Mike Rowe... When did the CEO/Mgrs making decisions that impact operational safety last do a risk management training program, CRM, SA, or any other training related to their direct (and inexorable) impact on safety? MOL, the poisoned dwarf? Please tear down the 6 story high "Zero Defects" sign inside the hangar... if the system believed that then they are merely showing they are not aware they have humans with their natural variability within their organisation. (even more embarrassing when usually there are 2 or 3 broken aircraft underneath the sign, from crew performance issues).

[PJ2]

Dozy;

Let me suggest the following as one response; - very slightly philosophical but fully applicable in practical circumstances; - a) In an instrumentally-informed world where the notions of "technique" are privileged over the widespread presence of actual comprehension and capability and, b) when economics, cost-accounting/control, the notions of "efficiency" and the need for results are driven by time pressures, then formula-thinking and rote learning take precedence over competence.

"CRM" was an early response to major fatal accidents occurring to perfectly serviceable airplanes in benign circumstances. In my opinion, "CRM" begins with what we used to call 'good breeding', which can very loosely be described as having good manners, reasonable self-respect, respect for others no matter who they are or what they do and a healthy but not overbearing ego. I do not think that these notions are culturally-specific and instead they apply widely even as they may be informed by local culture.

As the causal pathways to accidents gradually shifted from aircraft design/mechanical/weather/navigation etc. causes to accidents resulting from human frailties, ways to combat such frailties had to be found. We all have heard of those early off the mark with these notions such as Perrow, (1984), Reason, Helmreich, Foushee and later Dekker and many others who are equally wonderful in their work.

The continued assessment and explanations of causal pathways moved outwards from the minds of individual pilots-in-control to the dynamics of all crew members in a single cockpit to the notions of organizational "failures". The latter was a critical and important leap in my view, but the human psyche was not set aside in this more expansive view of why accidents continue to occur.

Human factors became the primary, almost the only challenge remaining in aviation safety. One solution was a kind of "substitution of capacity" where designers realized that microchips could do the mundane stuff while the human watched and monitored. Another was to recognize that humans view the world in an intensely self-consistent way. Normally this is of little consequence. Almost all decisions in the operation of an airplane are not critical but in an emergency or when increasing stress levels, one's perceptions and therefore decisions become increasingly invested. As we all know from experience, asking someone under significant stress, (or no stress at all when they ought to be!), to change their mind has varying responses, very few of them productive in their own right...The "captain-as-god" syndrome was one such circumstance.

CRM belongs to the category of "technique" in a technically-informed world. It "works" because it is short-term, target-oriented, goals-driven and outcome-tested. It is formula-based. In my view, "good breeding" etc works immensely better but I realize the limitations of such a view.

Ideally, "CRM" just becomes a formal label for a whole series of small and timely behaviours which keep the operational conversation going while a) maintaining cockpit gradient and b) sustaining situational awareness.

CRM didn't "save" 232 or 1549; - there was no CRM involved, but absence of it as well as the absence of SOPs, cockpit discipline and airmanship initiated the accident sequence in 447.

I would just call CRM good, intelligent, experienced airmanship essentially invisible to those who practise it. From what I can observe from the sidelines now I think we are on the verge of losing it because we dwell in an instrumental world where the notions of "good breeding" are less and less relevant and in which the substitution of mere technique for an abiding competence is increasingly acceptable because it is faster/better/cheaper.

[DozyWannabe]

Originally Posted by fdr

Dozy, the human interaction in complex dynamic systems is critical.

Understood, sir. I may not be a pilot, but I like to think that neither am I a complete idiot (most of the time at any rate...). I can't live it the way you guys do, but I do my homework in order to understand the issues at hand as well as I can.

With experience, we learn to assess our colleagues in terms of how well we can work with them, and I think that one of the big differences in how colleague interaction works in earthbound professions like my own versus yours is that we can use that experience to avoid or keep to a minimum working with those we have trouble with. Pilots, on the other hand, are at the mercy of the crew roster and don't have that luxury.

The early renditions were related to dealing with communications more or less a rehash of signal theory and an awareness of Gert Hofsteade's treatise, thereafter we went towards organisational causation per James Reason, expansion of team dynamics with Dan Maurino, HMI/automation by Asaf Degani & Earl Weiner, and thereafter towards SA, Mica Endsley & Co, Threat and Error Management etc, with additional research from Neil Johnson and Co, Gary Klein NDM, RPDM etc.

Sure, and I bet that when the essence of all those theories and research papers is boiled down, what you ultimately end up with is a variant of PJ2's beautifully concise precis of being able to fly, communicate - and manage, in the case of being Captain - successfully at the same time.

In a well-run and organised flight deck environment staffed with people who are professionals first and foremost (e.g. those of Capts. Haynes, Sullenberger and Burkill, to name but a few), then the fundamental underpinnings of CRM are almost an afterthought because they happen instinctively. Yourself and PJ2 are of the opinion that because it is an instinctive and natural progression it is not therefore CRM. I'm not so sure myself, but as it's ultimately a philosophical difference I'm not going to argue.

EDIT : PJ2 - I actually wrote the above paragraph prior to seeing your reply. I think we're by-and-large on the same page here.

PS. I never said CRM "saved" 1549 or 232 - I paraphrased Bob McIntosh's assertion that the 232 CVR demonstrated the principles that underpin CRM in action.

Conversely when things go wrong, more often than not at least some of the factors can be traced to poor application of CRM fundamentals. Not just in cases such as BEA548 and Tenerife where the autocratic tendencies of the flight commander rendered the rest of the crew's input moot, but also cases like Palm 90, where the FO was in fact more experienced in jet operations than his Captain (who was far from autocratic in this case) and yet provided only token protests at a situation he knew was becoming unsafe; and EAL401 in which the whole crew allowed a minor technical problem to distract them - to the extent that no-one was monitoring the aircraft. Most if not all of these pre-date the initial heyday of CRM, but would you not say the principles still apply?

it cannot be a replacement for the fundamental skill sets of dealing with an aircraft as a simple physical tool.

Agreed, however I think we're talking about a separate issue from CRM at this point. If you know of an operation where CRM or similar HF training is being performed at the expense of flight training, then that needs to be reported.

Being unable to recognise a stall, or recover from a stall is an unacceptable point to have achieved.

Agreed, and we'll get back to that shortly.

A320/330's etc stall quite well, just needs a dynamic change to exceed the program envelope and you are on your way to a fun ride. Don't even need a system failure

I'm pretty sure you do. The incidents you mention all show the aircraft dropping out of Normal Law prior to stalling. By definition this means that a systems failure was involved.

but they apparently happen routinely

Could you provide me a link to the third example? Working on the assumption you're right, I'd hardly call 3 incidents in nearly a quarter-century of service "routine".

I believe in education and increased self awareness, as it assists in understanding the environment we work in.

As do I.

It is not a replacement for core skills, and that is what is currently killing us.

I think we need to look at a few things here. Firstly the advent of CRM occurred roughly in the same time period as the widespread introduction of powerful digital FMS and automation, but I suspect this is a coincidence - please correct me if you know differently but I can't help but doubt that the two were intended to complement each other.

In that same time period, business practices (particularly in the west) started moving towards managerialism. PJ2 wrote a wonderful post a while back -detailing the encroachment of the MBA generation on airline management and ops. I won't try to paraphrase it here, but the core of it related to how, prior to this shift, senior management tended to have been aviation people first and foremost. MBA training on the other hand tends to focus on finance, manufacturing and retail, and to adapt the methods suited to those sectors to fit everything else.

Now for example, in manufacturing you train an employee to perform a role - that training can be bolstered by the education and training that employee previously had. Putting that aside for a second, as the employee gains experience with the company they may be required to undergo further training when new tools and methods are adopted, and sometimes refresher training is required to brush up on specifics. The manager can usually assume quite safely that said employee will never have to revisit the basics that they learned either prior to or on joining the company because it becomes second nature - in fact to do so would be an arguably unnecessary expense.

I'm sure you don't need me to point out the potential for danger in applying this mentality to pilots, but a manager whose MBA bought them a place in an airline without having to understand the shop floor will be completely clueless. As such they do not comprehend how practicing stall recovery in CAVOK conditions in a Cessna is in no way, shape or form sufficient preparation for dealing with a stall in an airliner over water at night. All they know is that the pilot came to them with a bunch of certificates that tick the "trained in stall recovery" box.

It is this mentality above all else that I believe is the crux of the problem. Everything else - including CRM, automation, SOP practice etc. - is a sideshow by comparison. Believe me, it's a problem across industry as a whole - aviation is not alone.

Now - circuitously getting back to the subject, I see a failure to apply PJ2's principles in the Turkish accident case. But I do not see sufficient evidence to support a conclusion that these systemic issues were at the heart of the loss of SA.

Phew! Sorry for the ramble, all...

[fdr]

PJ, thanks. Missed Bob H in my comments. The weight of the world was on his shoulders...

Doz,

Conversely when things go wrong, more often than not at least some of the factors can be traced to poor application of CRM fundamentals. Not just in cases such as BEA548 and Tenerife where the autocratic tendencies of the flight commander rendered the rest of the crew's input moot, but also cases like Palm 90, where the FO was in fact more experienced in jet operations than his Captain (who was far from autocratic in this case) and yet provided only token protests at a situation he knew was becoming unsafe; and EAL401 in which the whole crew allowed a minor technical problem to distract them - to the extent that no-one was monitoring the aircraft. Most if not all of these pre-date the initial heyday of CRM, but would you not say the principles still apply?

I think that is the point PJ and I, and some others are starting to make. The application of CRM in itself doesn't make for a competent pilot, but a competent pilot without CRM is a PITA and has potential safety issues. Problem solving when you have a failure of the basic ability to aviate a J3 Cub is going to end badly. Have watched crews run all the decision making protocols to ground while going around in a circle, until the engines run dry. 3 out of 3 crews... checked by the training organisation associated with the non airbus company, driven to distraction. Have personally called for an emergency checklist and received a suggestion we contact the company some 2000nm away over the ether... the failure of the A.N.C. priority and the vice like grip on the trivial does not make for safer operation, in fact, my suspicion is we have descended into the rabbit hole and are now confronted by the surreal situation that the pilot ain't a pilot. Not a case of automation vs manual driving, just having crew that have actually flown real aircraft and understand implicitly how they work. Kind of like motorcycling... all the reading in the world won't make up for actually getting out there and having the experiential immersion and skinned knees.

[BOAC]

As others have said, this is an extremely valuable topic (Could the mods give it its own space and merge the posts?)

Like some others, I see the 'CRM' concept as either 'inbuilt' or 'no way', but what I think the CRM topic does is to make the receptive folk THINK and perhaps realise there are areas where they can improve approachability and team play. Like PJ, during my 'initial' (one of the relatively early ones - 1988 with DanAir) we had the 'over my dead body' brigade who really needed the exercise, and the others, and I had to spend more than a few legs being berated by Captains in the former group as to how the whole thing was a 'complete waste of time'.

Where I do see the problem is where the concept has gradually been hijacked and expanded into an industry (rightly) involving just about all from bottom to top (excluding, sadly, operational management in many cases) and thus further alienating those 'non-believers'.

Like 'airmanship', I believe the concept is basically innate, and it takes a very disciplined person to counter any innate personality 'defects' when under high stress. I suspect most of the 'shining examples' we have highlighted above had a well-founded innate structure which carried them through the jungle. 'Natural evolution' has drastically reduced the numbers of now Captains who grew up under the glare of the old 'Captain is god', and will further improve. We are probably just coming to the end of the first 'post' generation.

Originally Posted by DW

Firstly the advent of CRM occurred roughly in the same time period as the widespread introduction of powerful digital FMS and automation, but I suspect this is a coincidence - please correct me if you know differently

- I believe it does effectively 'pre-date' this period. What happened subsequently was well demonstrated by BA and its 'glass cockpit awareness' ('EOI') courses to try to address these later issues (and excellent they were in my opinion.)

[DozyWannabe]

@BOAC - I was thinking roughly late '70s. Was it in fact earlier as far as you know?

Cheers!

Originally Posted by fdr

The application of CRM in itself doesn't make for a competent pilot, but a competent pilot without CRM is a PITA and has potential safety issues.

Would you not consider it fair to say additionally that pilots who have demonstrated above-average levels of competence tend to show the traits that make up the underpinnings of CRM (whether they've been trained in CRM or not)?

Problem solving when you have a failure of the basic ability to aviate a J3 Cub is going to end badly.

Fundamentally, should it not be the case that qualified pilots have the ability to do so when they begin their line careers? The issue is in refreshing those basics from time to time, and translating their PPL experience to the larger types they are now flying, no?

...just having crew that have actually flown real aircraft and understand implicitly how they work.

Modern airliners are still real aircraft no matter how much automation they have - I'd say the danger is in management failing to realise this.

Originally Posted by BOAC

...what I think the CRM topic does is to make the receptive folk THINK and perhaps realise there are areas where they can improve approachability and team play.

Aye, and from another perspective, develop methods of dealing with the less-receptive people that will defuse any problems without putting the conduct of the flight at risk.

[BOAC]

@BOAC - I was thinking roughly late '70s. Was it in fact earlier as far as you know?

- no. I guess it depends on the subjectivity of one's view of "the widespread introduction of powerful digital FMS and automation" - I did not see that as far back as the 70's

[DozyWannabe]

The first in-service full-featured FMS was on the A300, which went into service in 1974. Adoption snowballed with the introduction of the B767 and B757 in 1982 and 1983 respectively (though they'd both been in development since the mid-'70s). Therefore I picked the late '70s as a median, the point at which the industry committed to making the technology a part of the modern flight deck.

[fdr]

Would you not consider it fair to say additionally that pilots who have demonstrated above-average levels of competence tend to show the traits that make up the underpinnings of CRM (whether they've been trained in CRM or not)?

No, I think I would disagree. I would think that being above-average competence is not necessary to show the traits that make up the underpinnings of CRM. The great unwashed majority of flight crew are competent. The industry problem is that the outliers are problematic, and overrepresented often, (but not always) in the funny pages. (The great majority used to be washed, but then the industry came on hard times, hot water is now a luxury, except if you have annoyed your management...). 80:20 rule.

[BARKINGMAD]

New Improved Aerodynamics. Post# 2844.

Quote:
Originally Posted by BARKINGMAD
I was under the impression that the PF onboard AF447 maintained too high a nose attitude for the phase of flight
...
As opposed to the THY, where the PF maintained (manually or via the a/p) too high a nose attitude for the phase of flight...

Technically correct, but in the case of AF447 the PF deliberately pulled up and kept pulling up despite such inputs being wildly inappropriate for the flight phase. The THY crew as far as I know did not - their stall resulted from failing to monitor thrust and airspeed while holding what would be a normal pitch attitude for approach - your mileage may vary, but I think that's a pretty significant difference.

Having just woken up and noticed this, Dozy, please tell me how the THY could FOLLOW THE GLIDEPATH with :
1. Idle thrust
2. Low decreasing IAS
3. Flap & gear deployed
but without an increasing AOA manifested by an abnormally high nose attitude for the configuration?

Is there something I missed during my ground skule and subsequent practising aviation (and training others in the black arts of flying) that says the basic pich attitude has no bearing on the approaching stall in unaccelerated (1G) flight? If there is, I need to know before I try the same trick on my next line flight!

I note with interest you say you are not a line pilot, but obviously aware of factors affecting how aircraft fly and crash and your posts seem to cause contoversy and provoke replies to that effect!

Can you recap on your aviation qualifications for the benefit of other readers? You sneaked in this unusual concept of how planes fly, so I politely request further clarification so's I can amend my Betty Windsor's noddys giuide to aviation!

[Roger Greendeck]

From my recollection of this accident one of the key if not the key error was the disregarding of stabilised approach criteria. This technical fault had occured on a number of occasions previously without going close to the same result.

They got very busy late in the approach trying to join the glideslope from above. Whilst it is possible for a crew with good SA to successfully and safely land an aircraft after getting stable late the reality is that the chances deminish very quickly the close you get to the ground. In this case the normal ques that would have let them know they had a problem were masked by the high ROD and low power required to join from above. They were distracted by trying to still get checks done whilst things were already going wrong. If they had knocked off the approach when they went through the stabilised approach point it would have ended without any of us knowing about it.

[Chronus]

Human Factors and THY Schipol crash

CRM is very much a matter concerning human factors. It is an attempt to recognise and reduce as much as possible from the inadequacies and failings inherent in us all as human beings.
Whilst the discussions on this forum seem to have centered on these failings which have in one way or another led to major catastrophes, there is an apparrent lack of any discussion where the ocurrence of events capable of a major catastrophy were succesfully contained and disaster was not the outcome of the event. A good example is the Air Transat Airbus A330, sometime referred to as The Azores Glider. Should we not consider what the crew did not do rather than what they did and how did the character, personality and background of the crew affect the outcome. On my part for what it is worth, all on board were truly lucky to have had Captain Piche sitting at the right seat on that flight, an admirable example of our imperfect human race. So lets be careful out there, we don`t want to throw out the baby with the bath water now do we, in all our ever deepening search, research and analysis of all the CRM, Human Factors and probes into every nook and cranny of all and every brain cell.

[Roger Greendeck]

You mean the spectacular glide approach that was pulled off after having transfered all their fuel out of the side with a leak?

Whilst I agree they did a good job once the engines stop lets not forget that it was their basic error that got them there in the first place. A fuel imbalance doesn't just happen all by itself.

The reality is that we don't know about most of the serious malfunctions that are successfully landed because we only hear about the crashes or near misses where the pax are aware of the problem and the media pick up on it.

This particular malfunction had occured numerous times and was handled without difficulty. Which was why no-one who was aware of this re-occuring fault was that big of a problem.

[CONF iture]

Originally Posted by Roger Greendeck

You mean the spectacular glide approach that was pulled off after having transfered all their fuel out of the side with a leak?

... transferred the fuel into the side with the leak.
But don't forget that feeding the leak was partly done by the automatic fuel transfer.

[blind pew]

Dozy

"BEA548"
I must correct you on your statement re autocratic captain..whilst somewhat correct the accident cause lies in an incompetent bullying management, incorrect training and poor maintanence. This was reflected in the press of the time but the inquiry's conclusions were incorrect..partly due to evidence being withheld or manipulated.

[Chronus]

thy Schipol

Roger Greendock seems to have missed the point. Humans make lots of mistakes, what matters is how they handle a given situation. Yes, of course we learn after a terrible event, but why not consider CHIRP, surely this is not just merely a confessional booth, added to which there are lots and lots of incident reports where the final outcome was not catastrophic.
Survival stories are so much more interesting than those that end up with wholesale carnage. From time to time we need to have a reality check and remind ourselves that our environment is real and that it is not a computer grenerated image commanded by a multitude of little buttons and switches.
The book "Robert Piche Hands on Destiny" by Pierre Cayoutte is a good read, it is not so much about the incident as it is about the man. The title says it all.