Turkish airliner crashes at Schiphol
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@BALLSOUT
Read the posts, because A/T was thinking the plane is on the ground due to false RA input. Should crew have noticed this, yes they did but due to "distraction" too late.
The question is, why did the crew not notice that when the speed had reduced to what they had selected, did the autothrust not start to come back in?
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On the type that I fly- BAe RJ 100- there are only 4 things that are permitted to fail on a autoland approach without requiring you to go around. And one of the four is a radalt.
In other words with a radalt failure you can still complete an autoland or a non autoland approach.
Here, though, we are being told that a single radalt failure on a (modern) Boeing 737 brought the levers to flight idle and caused a stall.
So either.
1. Avro are really clever manufacturers
2. Boeing aren't
3. This 'radalt' theory from the Dutch is rot.
Which is it?
In other words with a radalt failure you can still complete an autoland or a non autoland approach.
Here, though, we are being told that a single radalt failure on a (modern) Boeing 737 brought the levers to flight idle and caused a stall.
So either.
1. Avro are really clever manufacturers
2. Boeing aren't
3. This 'radalt' theory from the Dutch is rot.
Which is it?
Apologies if this has been mentioned before, but it would appear that had this been an A320, Alpha Floor would have automatically applied maximum thrust and saved the aircraft.
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Totally agree with Blacksheep, it's important we find out what on earth distracted the crew to the point of not spotting something as basic as decaying airspeed... There are always lessons to be learned.
If it turns out that it is the crew chit-chatting to each other, then I guess yes maybe this really is a case of dreadful airmanship...
If it is something else, like a nuisance warning, it might be worth discussing the current DODAR (or equivalent) methodology. All TREs would tell you they see crews not flying the airplane far more often than you'd think. Most likely when a warning, sound or smell does not seem to match any known scenario. Maybe troubleshooting methodology should include a very clear reminder, right at the onset of the problem, about who is flying the airplane. And part of PM duties should be to remind the PF to get back to his/her instruments if he/she starts getting too involved (not easy if PM is young F/O and PF getting frustrated by e.g. F/O taking too long to find correct QRH section)
I know it sounds obvious and hopefully most of us would do that without having to go through any type of mnemonic. But like I said, TREs see that role separation brake down on a regular basis.
No need to reply with "but this is basic airmanship!". Yes it is. Yes I know that. But yes, continuously improving CRM methodology does save lives.
P
If it turns out that it is the crew chit-chatting to each other, then I guess yes maybe this really is a case of dreadful airmanship...
If it is something else, like a nuisance warning, it might be worth discussing the current DODAR (or equivalent) methodology. All TREs would tell you they see crews not flying the airplane far more often than you'd think. Most likely when a warning, sound or smell does not seem to match any known scenario. Maybe troubleshooting methodology should include a very clear reminder, right at the onset of the problem, about who is flying the airplane. And part of PM duties should be to remind the PF to get back to his/her instruments if he/she starts getting too involved (not easy if PM is young F/O and PF getting frustrated by e.g. F/O taking too long to find correct QRH section)
I know it sounds obvious and hopefully most of us would do that without having to go through any type of mnemonic. But like I said, TREs see that role separation brake down on a regular basis.
No need to reply with "but this is basic airmanship!". Yes it is. Yes I know that. But yes, continuously improving CRM methodology does save lives.
P
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Ken
The radalt did not "fail". It gave a false value of -8 ft, which I reckon approximates to an immediate signal return from the aerial instead of the surface of the earth (since it reads -2 on the ground).
Anyone know of a history of this malfunction. Ice?
The radalt did not "fail". It gave a false value of -8 ft, which I reckon approximates to an immediate signal return from the aerial instead of the surface of the earth (since it reads -2 on the ground).
Anyone know of a history of this malfunction. Ice?
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Skill
There is quite a difference between a fighter aircraft and an airliner. If you're a good fighter pilot, doesn't mean you are a good line pilot. This should be understood by airline management, when deciding on hiring and training new pilots.
In some cultures you are a hero when you have a military background. We don't need "heroes" on the flightdeck. We need professionals struggling every day to improve themselves a bit more. (Ex military pilots included!)
In some cultures you are a hero when you have a military background. We don't need "heroes" on the flightdeck. We need professionals struggling every day to improve themselves a bit more. (Ex military pilots included!)
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I understand the systems discussions - they are very interesting, but isn't the point here that there was NOBODY FLYING THE AIRPLANE?
We teach all the new systems, procedures and sops, employ TAWS, HGS, EVAS, WAAS etc. etc.; automation is king these days, but we never fail to bully the crew that "somebody always is supposed to be flying the aircraft."
What happened to that?
I stopped saying "Aviate Navigate Communicate" because it was such a tired old saw that the guys I was training would roll their eyes back when I felt I had to say it. Get used to it because out it comes again.
If there are crews out there that are so complaisant that there was nobody watching the shop on final approach, I recommend night school or a real estate license because you are definitely in the wrong job.
We teach all the new systems, procedures and sops, employ TAWS, HGS, EVAS, WAAS etc. etc.; automation is king these days, but we never fail to bully the crew that "somebody always is supposed to be flying the aircraft."
What happened to that?
I stopped saying "Aviate Navigate Communicate" because it was such a tired old saw that the guys I was training would roll their eyes back when I felt I had to say it. Get used to it because out it comes again.
If there are crews out there that are so complaisant that there was nobody watching the shop on final approach, I recommend night school or a real estate license because you are definitely in the wrong job.
Per Ardua ad Astraeus
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Perma - it is very tempting to slip this one into the huge CRM arena, but I think it more important to re-emphsise the almost forgotten words "basic airmanship" as Boeing have had to. I expect they were 'too busy' at the time of the GPWS Gear warning to run through anything approaching DODAR, which has its place but really would call for a g/a to diagnose that one properly.
I do, of course, support your last sentance.
TP - I suspect it was just one of those 'wiggly amps/straight volt' things - I think from fading memory the ground reading is -4 and it MAY be that the 'dormant' reading is -8? Who knows?
I do, of course, support your last sentance.
TP - I suspect it was just one of those 'wiggly amps/straight volt' things - I think from fading memory the ground reading is -4 and it MAY be that the 'dormant' reading is -8? Who knows?
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Originally Posted by Jonty
Apologies if this has been mentioned before, but it would appear that had this been an A320, Alpha Floor would have automatically applied maximum thrust and saved the aircraft.
- It was not at Paris! It was at Habsheim, which is a long way from Paris
- The crew did not expect TOGA thrust to kick in, because they had deliberately disabled that feature (permanently disabled autothrust).
- This is completely irrelevant to this accident.
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Do you people not get that the Autothrottle and Autopilot are two independent systems?
The autothrottle will go from SPEED mode into RETARD at 27ft RA. It doesn't matter if you are flying manual or on the autopilot.
The Majorproblem is that 3 pilots failed to notice the thrust not being increased when the commanded speed was reached. There must have been a very very big green speed trend arrow pointing down. Subsequently as airspeed decreased below the commanded speed they must have noticed the following, increasingly higher pitch attitude, less noise (wind and thrust), speed entering yellow band on speed tape, speed entering red band, stick shaker! The initial indications should have led to disconnecting of the autothrottle, the later indications to a go-around.
Although a system fault caused the thrust to come back, simply standing up the thrust levers at Vref (without disconnecting the autothrust) and holding it there with muscle power would have prevented this. The lever position commands the thrust, so overriding the autothrottle is possible. Although you will feel pressure from the system trying to close the levers in RETARD mode. In a later stage a go-around (TOGA press) would have solved it.
They didn't, 3 pilots missed everything until they were at 400ft with a stickshaker. The question is why?
As far as i'm concerened there is nothing wrong with the design philosophy, this was a lack of basic flying combined with too much faith in the automatics!
So far any one that says flying raw data manually flown approaches in IMC is dangerous. Relying on automatics is equally dangerous, and when you need to takeover you might lack the skills to fly it out.
The autothrottle will go from SPEED mode into RETARD at 27ft RA. It doesn't matter if you are flying manual or on the autopilot.
The Majorproblem is that 3 pilots failed to notice the thrust not being increased when the commanded speed was reached. There must have been a very very big green speed trend arrow pointing down. Subsequently as airspeed decreased below the commanded speed they must have noticed the following, increasingly higher pitch attitude, less noise (wind and thrust), speed entering yellow band on speed tape, speed entering red band, stick shaker! The initial indications should have led to disconnecting of the autothrottle, the later indications to a go-around.
Although a system fault caused the thrust to come back, simply standing up the thrust levers at Vref (without disconnecting the autothrust) and holding it there with muscle power would have prevented this. The lever position commands the thrust, so overriding the autothrottle is possible. Although you will feel pressure from the system trying to close the levers in RETARD mode. In a later stage a go-around (TOGA press) would have solved it.
They didn't, 3 pilots missed everything until they were at 400ft with a stickshaker. The question is why?
As far as i'm concerened there is nothing wrong with the design philosophy, this was a lack of basic flying combined with too much faith in the automatics!
So far any one that says flying raw data manually flown approaches in IMC is dangerous. Relying on automatics is equally dangerous, and when you need to takeover you might lack the skills to fly it out.
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I agree with BOAC, less heat on Boeing. Human factors most probable from what has been posted so far(not just on here).
The Captain's Radio altimeter was known to be faulty?
On LOC/GS autopilot disengages 2 sec after capture. This scenario started at about at 2000'agl?Isn't that the platform altitude for the ILS's into AMS?Company culture, national culture, a ''man and boy'' operation, afraid to speak up, 2 FO's on the flight deck one being a safety FO?These are the questions that have to be asked as well putting sensitivities to culture/tradition aside.
Regardless of company SOP or not guarding the controls is airmanship. I have found the best way to be in tune with the machine. On how many occasions when on the jumpseat I found crews engaging in non operational chatter which detracts one's attention. This used to occur regularly with one guy who was hell bent on anti CRM policies of the said operator and treated FO's with contempt.
Now we have to brief on the cabin/configuration warning and subsequent actions should it activate inflight. Wasn't that already a recall action ever since the aeroplane was first certified? Why didn't a certain crew do just that in the first place?There are numerous ''swiss holes'' during each flight and before we know it maybe the QRH will become a recall item which in turn would overload and make crew's to overlook/forget and thus rendering the system useless. Our manuals are already trimmed down to nothing because of this ''liability factor'' and are instead written by Lawyers that do noting to help a crew's collective knowledge. How many on here were quick to pint to Boeing about not writing anything about this?How many times have we been shown something in the simulator that is not written anywhere? And the very use of this ''where is it written'' material is not acceptable to operators due to the potential for liability and crew's are discouraged from using unofficial information.The only way to guard against this is to understand our job and follow procedures. And that can only be achieved with information.
How many deaths happen in the medical profession each year?And on the flip side more information is added each day to educate/train the medical profession. In our profession the opposite is true due to the Layer factor and management's pursuit for profits. Hopefully we can all learn something from this tragic event and especially sausage factories for pilots that try and create the Macdonalds for Airline pilots of tomorrow. That is a clear demonstration of a latent failure in/by the present system, as recently warned by the Hudson Hero. Did anyone listen?
The Captain's Radio altimeter was known to be faulty?
On LOC/GS autopilot disengages 2 sec after capture. This scenario started at about at 2000'agl?Isn't that the platform altitude for the ILS's into AMS?Company culture, national culture, a ''man and boy'' operation, afraid to speak up, 2 FO's on the flight deck one being a safety FO?These are the questions that have to be asked as well putting sensitivities to culture/tradition aside.
Regardless of company SOP or not guarding the controls is airmanship. I have found the best way to be in tune with the machine. On how many occasions when on the jumpseat I found crews engaging in non operational chatter which detracts one's attention. This used to occur regularly with one guy who was hell bent on anti CRM policies of the said operator and treated FO's with contempt.
Now we have to brief on the cabin/configuration warning and subsequent actions should it activate inflight. Wasn't that already a recall action ever since the aeroplane was first certified? Why didn't a certain crew do just that in the first place?There are numerous ''swiss holes'' during each flight and before we know it maybe the QRH will become a recall item which in turn would overload and make crew's to overlook/forget and thus rendering the system useless. Our manuals are already trimmed down to nothing because of this ''liability factor'' and are instead written by Lawyers that do noting to help a crew's collective knowledge. How many on here were quick to pint to Boeing about not writing anything about this?How many times have we been shown something in the simulator that is not written anywhere? And the very use of this ''where is it written'' material is not acceptable to operators due to the potential for liability and crew's are discouraged from using unofficial information.The only way to guard against this is to understand our job and follow procedures. And that can only be achieved with information.
How many deaths happen in the medical profession each year?And on the flip side more information is added each day to educate/train the medical profession. In our profession the opposite is true due to the Layer factor and management's pursuit for profits. Hopefully we can all learn something from this tragic event and especially sausage factories for pilots that try and create the Macdonalds for Airline pilots of tomorrow. That is a clear demonstration of a latent failure in/by the present system, as recently warned by the Hudson Hero. Did anyone listen?
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BOAC, you're probably right that basic airmanship IS the problem here... But what is the solution? How do we improve it? I don't think there is an easy answer. Should we all start flying many more manual approaches? Very busy airspaces, four/five/six sector days in busy terminal areas - is that really going to improve safety? I'm not sure. Can it be fixed in the sim? I'm even less sure. Very tough problem.
P
P
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Although I appreciate that there are many 73 drivers here keen to discuss the A/C tech side of things I feel there is something more sinister lurking in the background of this and other recent incidents that will come back to haunt us time and time again - 'as mentioned before' - lack of basic flying skill.
We now live in an age where we are encouraged to use automation to the full on the line (hand flying an approach is frowned upon) and then every 6 months go to practise in the sim only to find that we are advised to use the automatics to the full in there as well.
Where and when are we supposed to practise the most basic of flying skills ?
Not all of us are able to fly a light A/C on our days off.
Point he finger of blame at the crew as much as you want but this and other recent incidents are little glimpses at the changes the industry is going through.
We now live in an age where we are encouraged to use automation to the full on the line (hand flying an approach is frowned upon) and then every 6 months go to practise in the sim only to find that we are advised to use the automatics to the full in there as well.
Where and when are we supposed to practise the most basic of flying skills ?
Not all of us are able to fly a light A/C on our days off.
Point he finger of blame at the crew as much as you want but this and other recent incidents are little glimpses at the changes the industry is going through.
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Would you not expect A/T to disarm automatically with a big fat warning when RA provides "illogical" data as in this case? -8 would be a value which only a defective RA can deliver as the lowest on ground is -2.
Suppost at 1950 there would have been a warning about the defective RA and A/T would have been disabled with a clear warning (not gear down as RA is the issue), then crew would have been warned with correct situative information and would have prevented this from happening.
Systems that do not provide clear and precise feedback are only good for disasters waiting to happen. Afaik Boeing need to fix this flaw.
Suppost at 1950 there would have been a warning about the defective RA and A/T would have been disabled with a clear warning (not gear down as RA is the issue), then crew would have been warned with correct situative information and would have prevented this from happening.
Systems that do not provide clear and precise feedback are only good for disasters waiting to happen. Afaik Boeing need to fix this flaw.
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Airspeed Awareness
OK.....I'm showing my age but, what do you call these 'new' airspeed indicators, a PFD or something? Everything's on one instrument now! Anyway, they are NOT pointer style indicators "like we used to have" in the way back. There's lots of talk here about not noticing the speed decay. I'm wondering it it isn't harder to notice speed decay with this 'newer' style vs the pointer syle we used to have. I'm betting the newer ones are harder to spot speed changes. Thoughts?
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We now live in an age where we are encouraged to use automation to the full on the line (hand flying an approach is frowned upon) and then every 6 months go to practise in the sim only to find that we are advised to use the automatics to the full in there as well.
Where and when are we supposed to practise the most basic of flying skills ?
Where and when are we supposed to practise the most basic of flying skills ?
"Frowned" ? I don't care! I do about 50% of the approaches out of 10k feet manually, traffic and weather situation permitting.
Europe, major carrier, short range.
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Boeing Statement
Subject: 737-800 TC-JGE Accident at Schiphol Airport, Amsterdam - 25 February 2009
FROM: THE BOEING COMPANY
TO: MOM [MESSAGE NUMBER:MOM-MOM-09-0063-01B] 04-Mar-2009 05:29:01 AM US PACIFIC TIME Multi Operator Message
This message is sent to all 737-100,-200,-300,-400,-500,-600,-700,-800,-900,-BBJ customers and to respective Boeing Field Service bases, Regional Directors, the Air Transport Association, International Air Transport Association, and Airline Resident Representatives.
SERVICE REQUEST ID: 1-1228079803
ACCOUNT: Boeing Correspondence (MOM)
DUE DATE: 10-Mar-2009
PRODUCT TYPE: Airplane
PRODUCT LINE: 737
PRODUCT: 737-100,-200,-300,-400,-500,-600,-700,-800,-900,-BBJ ATA: 3400-00
SUBJECT: 737-800 TC-JGE Accident at Schiphol Airport, Amsterdam - 25 February 2009
REFERENCES: /A/ 1-1222489391 Dated 25 February 2009
Reference /A/ provides Boeing's previous fleet communication on the subject event. The US NTSB, FAA, Boeing, the Turkish DGCA, the operator, the UK AAIB, and the French BEA continue to actively support the Dutch Safety Board's (DSB) investigation of this accident.
The DSB has released a statement on the progress of the investigation and has approved the release of the following information.
While the complex investigation is just beginning, certain facts have emerged from work completed thus far: -
To date, no evidence has been found of bird strike, engine or airframe icing, wake turbulence or windshear.
There was adequate fuel on board the airplane during the entire flight.
Both engines responded normally to throttle inputs during the entire flight.
The airplane responded normally to flight control inputs throughout the flight.
The Digital Flight Data Recorder (DFDR) data indicates that the crew was using autopilot B and the autothrottle for an ILS (Instrument Landing System) approach to runway 18R at Amsterdam Schiphol airport. During the approach, the right Low Range Radio Altimeter (LRRA) was providing accurate data and the left LRRA was providing an erroneous reading of -7 to -8 feet. When descending through approximately 2000 feet the autothrottle, which uses the left radio altimeter data, transitioned to landing flare mode and retarded the throttles to the idle stop. The throttles remained at the idle stop for approximately 100 seconds during which time the airspeed decreased to approximately 40 knots below the selected approach speed.
The two LRRA systems provide height above ground readings to several aircraft systems including the instrument displays, autothrottle, autopilots and configuration/ground proximity warning. If one LRRA provides erroneous altitude readings, typical flight deck effects, which require flight crew intervention whether or not accompanied by an LRRA fault flag, include:
Large differences between displayed radio altitudes, including radio altitude readings of -8 feet in flight.
Inability to engage both autopilots in dual channel APP (Approach) mode
Unexpected removal of the Flight Director Command Bars during approach
Unexpected Configuration Warnings during approach, go-around and initial climb after takeoff
Premature FMA (Flight Mode Annunciation) indicating autothrottle RETARD mode during approach phase with the airplane above 27 feet AGL. There will also be corresponding throttle movement towards the idle stop. Additionally, the FMA will continue to indicate RETARD after the throttles have reached the idle stop
Boeing Recommended Action - Boeing recommends operators inform flight crews of the above investigation details and the DSB interim report when it is released. In addition, crews should be reminded to carefully monitor primary flight instruments (airspeed, attitude etc.) and the FMA for autoflight modes. More information can be found in the Boeing 737 Flight Crew Training Manual and Flight Crew Operations Manual.
Operators who experience any of the flight deck effects described above should consult the troubleshooting instructions contained in the 737 Airplane Maintenance Manual. Further, 737-NG operators may wish to review 737NG-FTD-34-09001 which provides information specific for the 737-NG installation. Initial investigations suggest that a similar sequence of events and flight deck indications are theoretically possible on the 737-100/-200/-300/-400/-500. Consequently the above recommendations also apply to earlier 737 models.
Operators will be notified if further action is recommended.
Jack Trunnell Director - Fleet Support Engineering Technical Customer Support Commercial Aviation Services The Boeing Company
FROM: THE BOEING COMPANY
TO: MOM [MESSAGE NUMBER:MOM-MOM-09-0063-01B] 04-Mar-2009 05:29:01 AM US PACIFIC TIME Multi Operator Message
This message is sent to all 737-100,-200,-300,-400,-500,-600,-700,-800,-900,-BBJ customers and to respective Boeing Field Service bases, Regional Directors, the Air Transport Association, International Air Transport Association, and Airline Resident Representatives.
SERVICE REQUEST ID: 1-1228079803
ACCOUNT: Boeing Correspondence (MOM)
DUE DATE: 10-Mar-2009
PRODUCT TYPE: Airplane
PRODUCT LINE: 737
PRODUCT: 737-100,-200,-300,-400,-500,-600,-700,-800,-900,-BBJ ATA: 3400-00
SUBJECT: 737-800 TC-JGE Accident at Schiphol Airport, Amsterdam - 25 February 2009
REFERENCES: /A/ 1-1222489391 Dated 25 February 2009
Reference /A/ provides Boeing's previous fleet communication on the subject event. The US NTSB, FAA, Boeing, the Turkish DGCA, the operator, the UK AAIB, and the French BEA continue to actively support the Dutch Safety Board's (DSB) investigation of this accident.
The DSB has released a statement on the progress of the investigation and has approved the release of the following information.
While the complex investigation is just beginning, certain facts have emerged from work completed thus far: -
To date, no evidence has been found of bird strike, engine or airframe icing, wake turbulence or windshear.
There was adequate fuel on board the airplane during the entire flight.
Both engines responded normally to throttle inputs during the entire flight.
The airplane responded normally to flight control inputs throughout the flight.
The Digital Flight Data Recorder (DFDR) data indicates that the crew was using autopilot B and the autothrottle for an ILS (Instrument Landing System) approach to runway 18R at Amsterdam Schiphol airport. During the approach, the right Low Range Radio Altimeter (LRRA) was providing accurate data and the left LRRA was providing an erroneous reading of -7 to -8 feet. When descending through approximately 2000 feet the autothrottle, which uses the left radio altimeter data, transitioned to landing flare mode and retarded the throttles to the idle stop. The throttles remained at the idle stop for approximately 100 seconds during which time the airspeed decreased to approximately 40 knots below the selected approach speed.
The two LRRA systems provide height above ground readings to several aircraft systems including the instrument displays, autothrottle, autopilots and configuration/ground proximity warning. If one LRRA provides erroneous altitude readings, typical flight deck effects, which require flight crew intervention whether or not accompanied by an LRRA fault flag, include:
Large differences between displayed radio altitudes, including radio altitude readings of -8 feet in flight.
Inability to engage both autopilots in dual channel APP (Approach) mode
Unexpected removal of the Flight Director Command Bars during approach
Unexpected Configuration Warnings during approach, go-around and initial climb after takeoff
Premature FMA (Flight Mode Annunciation) indicating autothrottle RETARD mode during approach phase with the airplane above 27 feet AGL. There will also be corresponding throttle movement towards the idle stop. Additionally, the FMA will continue to indicate RETARD after the throttles have reached the idle stop
Boeing Recommended Action - Boeing recommends operators inform flight crews of the above investigation details and the DSB interim report when it is released. In addition, crews should be reminded to carefully monitor primary flight instruments (airspeed, attitude etc.) and the FMA for autoflight modes. More information can be found in the Boeing 737 Flight Crew Training Manual and Flight Crew Operations Manual.
Operators who experience any of the flight deck effects described above should consult the troubleshooting instructions contained in the 737 Airplane Maintenance Manual. Further, 737-NG operators may wish to review 737NG-FTD-34-09001 which provides information specific for the 737-NG installation. Initial investigations suggest that a similar sequence of events and flight deck indications are theoretically possible on the 737-100/-200/-300/-400/-500. Consequently the above recommendations also apply to earlier 737 models.
Operators will be notified if further action is recommended.
Jack Trunnell Director - Fleet Support Engineering Technical Customer Support Commercial Aviation Services The Boeing Company
To address the issue of the thrust lever position. They were in exactly the position the flightcrew expected them to be for most of the approach until the speed started to decay.
The aircraft intercepted the localiser beyond the normal descent point and appears to have been hot and high by several hundred feet initially. As they got a gear warning they were obviously gear up. They then rushed to configure the aircraft as quickly as possible. Anyone who flies the NG will know that from above the glide, with this kind of wind, this takes time unless you bust limits.
You can only complete the landing checklist when fully configured. As this occured very late they appear to have been focussed on this and probably looking out for the runway, rather than registering that the autothrottle was not working as expected. This might explain why the 'pilot flying' left the automatics in so long. Had he been flying manually it is extremely unlikely that things would have deteriorated to the extent they did.
When they finally realised much too late what was happening they were too low to recover. Once again the fundamental error was not being stabilised early enough.
A more experienced 737 'pilot flying' would I believe have had the gear down and been busy configuring before the localiser intercept.
This is a classic case of swiss cheese holes lining up. Not being stabilised, combined with a minor technical problem and training / command gradient issues resulted in catastrophic failure.
The aircraft intercepted the localiser beyond the normal descent point and appears to have been hot and high by several hundred feet initially. As they got a gear warning they were obviously gear up. They then rushed to configure the aircraft as quickly as possible. Anyone who flies the NG will know that from above the glide, with this kind of wind, this takes time unless you bust limits.
You can only complete the landing checklist when fully configured. As this occured very late they appear to have been focussed on this and probably looking out for the runway, rather than registering that the autothrottle was not working as expected. This might explain why the 'pilot flying' left the automatics in so long. Had he been flying manually it is extremely unlikely that things would have deteriorated to the extent they did.
When they finally realised much too late what was happening they were too low to recover. Once again the fundamental error was not being stabilised early enough.
A more experienced 737 'pilot flying' would I believe have had the gear down and been busy configuring before the localiser intercept.
This is a classic case of swiss cheese holes lining up. Not being stabilised, combined with a minor technical problem and training / command gradient issues resulted in catastrophic failure.
