Turkish airliner crashes at Schiphol

[DC-ATE]

Crew Assignments

I have yet to read anything "official" about the actual crew assignments. They have been listed as Captain, Co-Pilot, and Co-Pilot. Someone said they "heard" the Captain was in the right seat. That is a possibility if the "Co-Pilot was in fact a Captain who was transitioning to this aircraft. In which case that is perfectly legitimate. The question is: who signed the Release? The 3rd member's "postion" has NOT been stated.

[Dutch Bru]

BOAC, I agree with you that this is not an obvious discussion and I hope that the way I put forward things in my post reflects my understanding of the delicacy. I just could not help wondering.

I trust however that this will be addressed in the investigation of the DSB. Indeed in the prelim report it is stated that after the technical investigation they will concentrate on investigating the management of the crisis operations following the crash and what can be learnt from that.

Thanks,
Dutch

[captjns]

The question is: who signed the Release? The 3rd member's "postion" has NOT been stated

Who cares who signed the release... the AFCS did exactly what the crew programmed it to do... intentional or not. Bottom line there were allegedly three sets of competent eyes in the cockpit.

Its not the automation that kills innocent people that entrust their lives to airline crews... its the incompetence...

[dwshimoda]

737-800 trim wheel

Sorry if this is a stupid question, and it is slightly off topic:

I don't fly the 737, but have done 16 hours in a 737-300 simulator. I remember being initially scared stupid by the trim wheel spinning round, and noise it made! (Got used to it though) My aircraft doesn't have a trim wheel, so you don't get any sense of it trimming, other than by looking at the stab trim position indicator.

Does the NG also have a noisy trim wheel, and if so, would it not have been trimming back as it tried to stay on the GS? If so, would that not have been thought unusual by the crew?

Along with all the basic airmanship that goes with flying, including the absolutely critical instrument scan, I am always looking at the EPR commanded during descent - 1.18 is normally on the ball depending on weight & wind component, and anything significantly away from that would have me examining the flight path critically to ascertain why, before satsifying myself that the commanded EPR (or lack of) is correct for that phase of flight.

DW.

[paweas]

Seems our faith in the mighty Boeing design philosphy will have been shaken here,i recall reading a while ago on here a debate about moving throttles,strangly this situation would have been prevented with the Airbus alpha floor funtion wayy before the situation escalated into CFIT,automation must surely be the way forward as regardless of how many hours we have on a particular type sometimes us pilots need saving from ourselves... seems the old fashioned instrument scan was overlooked here by three pilots very sad but very eye opening for all of us.........

[dwshimoda]

Paweas...

strangly this situation would have been prevented with the Airbus alpha floor funtion wayy before the situation escalated into CFIT

I don't believe it would - Alpha Floor is inhibited below 100ft radalt - this radalt was showing -8ft.

This debate is not about Airbus Vs Boeing.

Your last sentence makes the most sense.

DW.

[captjns]

...seems the old fashioned instrument scan was overlooked here by three pilots very sad but very eye opening for all of us.

For the low time inexperienced button pushers one can only hope. Hopefully the comers to this automation will be more of an integral part of the operations side of the aircraft rather than relying on the automation.

But for the experienced airmen who should be in command of their aircraft???? why should this accident be an eye opener?

Best way to prevent CFIT is to keep in touch with situational awareness. Keep the charts out to confirm altitude and position and to make sure you are supposed to be where are supposed to be.

[HarryMann]

Lack of attention to thrust level:
One reason for the expectation that thrust might be Idle or low for an extended period might be a subconcious 'nod' to a fast and high G/S intercept ?
Lack of attention to speed:
Rushed approach with training dominating monitoring and aviating?


and

Originally Posted by OHNS

- the problem arises at the man/machine interface when either human beings or automated systems intrude or are called on to intervene in the other's territory.

Glaringly obvious maybe, but since we cannot reengineer human beings (yet), it's the automated systems interface to humans that need closer examination. Recent incidents show many failures in this area.

Good post!

[UNCTUOUS]

What was deadlier?

Was the deadlier development the stick-shaker and attempted stall recovery or was it the scenario mentioned by Belgique at post 647?.
.
i.e. At the stick-shaker, adding full-power with a fully back-trimmed elevator (courtesy autopilot's back-trimming into that stall to hold the glideslope) would surprise the PF (upon autopiot disconnect) - and lead to a steep nose-up attitude and a sharp nose-drop at the stall. That would be unrecoverable at low altitude and (as a characteristic of a power-on stall) once nose-low, lead to performance-destroying g-stalls - due to the pilot's perception of ground-rush - once clear of cloud.
.

[AfricanSkies]

Minimum speed reversion - under normal conditions, the A/P and A/T do not control to a speed which is less than minimum speed for the current flap config (about 1.3 Vs). If the actual speed goes below the minimum speed the underspeed limiting symbol appears in the MCP IAS display and the A/P will then command a speed 5 knots greater than minimum speed.

But this minimum speed reversion is not available after G/S capture.

However, with a radalt inop, the A/P will disconnect 2 seconds after LOC and GS capture and the A/T will NOT retard at flare.

So we have to assume the A/P kicked out after G/S capture, which would have compounded the rush and confusion on the flight deck whilst reengaging it.

But why did the A/T (which thought it was <27' and thus at flare) retard when it should not have?

During a single channel approach (which they sound like they were doing), the A/T will not flare anyway?

If the P1 radalt suddenly dropped to -8' then some more logic should have come into play, namely if Flare Mode is not armed by 350'agl, both A/P's disengage automatically.

Is it possible that just after G/S capture, 2 secs after to be precise, the A/P and A/T disconnected as they should have done because the P1 radalt was u/s, but as the crew struggled to re-engage the A/P and finish configuring, they forgot to re-engage the A/T (TLA already at idle), with the approach turning into a G/F the new F/O was out of the loop - his eyes not registering the decaying speed, the training captain wanted the aircraft configured and the checklists out of the way - his eyes were in the checklist and double-checking the items on it, by reading the checklist he's actively calling the new F/O's attention away from the ASI, and suddenly - stick shaker..

100 seconds at approach speeds from 180 down to 100 will take you how far? 4.5 to 5nm... how far is the G/S intercept from the threshold?

[Hot 'n' High]

W2P,

Unlike the Sea King accident you quote (1980 if I recall correctly?), I believe this crew dismissed the Rad Alt failure as being of no consequence and just got on with whatever they were doing as they flew down the ILS – some talk earlier of discussions about Checklists. It appears the consequence of this failure was not appreciated by the crew – and their PF/PM roles were simply non-existent to pick up the developing trend. The aircraft just did it’s own thing until the shaker went off. Having got totally “out the loop”, that must have come as a complete surprise.

Captjns,

But for the experienced airmen who should be in command of their aircraft???? why should this accident be an eye opener?

I guess it is not an "eye opener", just a "reminder" to us all that, however many 1,000 hours we have, aviation can bite if you are not watching it like a hawk. And hours, especialy of routine Ops, can lead to complacency. Not direct at you, that comment, but at us all. Guess that’s what this analysis is all about – What went wrong? How can you and I prevent it happening on our Watch?

[lakerman]

US Aviation Mags

Having recently received emails from both AVWeb and ATW I find the US Aviation magazines are just as bad as the Media. Both stating the a/c was brought down by a faulty altimeter, and both stating the a/p slowed the a/c not the a/t. These are supposed to be premier aviation knowledgeable out fits, but they cannot get it right. How do you expect SLF and joe public to get it right either.
Rainboe et al, you are facing anuphill struggle.
Sorry to get off topic but innaccurasies (inc my spelling) really get to me as well and is why I refrain from commenting normally

[BOAC]

FOR planeenglish and many others:

That report came out a while back and has been posted here a few times already. As you have quoted it, it is incorrect. The 'Autopilot' does not affect the Auto Throttle. Please take careful note of the comments of 'grizzled' above (1423).

For AfricanSkies - also a lot of'duff gen'.
1) The RadAlt was not technically 'u/s' as far as the system goes (read the thread?)
2) There is NO indication of the A/P 'kicking out' then.

So we have to assume the A/P kicked out after G/S capture, which would have compounded the rush and confusion on the flight deck whilst reengaging it.

OK?

But why did the A/T (which thought it was <27' and thus at flare) retard when it should not have?

Reading this thread will give you the answer - basically it worked 'on spec' for the reading it had.

During a single channel approach (which they sound like they were doing), the A/T will not flare anyway?

A/T does not 'FLARE'. It has no effect on the pitch (oh oh! Someone's going to come back on that, I just know it.) Autopilot does. Reading this thread will give....blah blah

If the P1 radalt suddenly dropped to -8' then some more logic should have come into play, namely if Flare Mode is not armed by 350'agl, both A/P's disengage automatically.

Single channel approach. Reading this thread will give....blah blah

Is it possible that just after G/S capture, 2 secs after to be precise, the A/P and A/T disconnected as they should have done because the P1 radalt was u/s

See above. Reading this thread will give....blah blah

Good God!

Lakerman - it could be the press are getting this c**p from here!

[Dysag]

DC-ATE

re training.

Just a question, to help me: do you recall it being written officially that the LH seat man was a "Training Captain" or some equally specific title?

I've searched but don't find such a clear statement.

I don't know how THY is organised, but I wonder about this gentleman's training time, or whether he was mostly a regular line captain.

[MU3001A]

737Jock

Thanks for confirming the A/T modes, in particular the RETARD at 27' RA with A/T engaged on a manual or autopilot flown approach.

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!

Setting aside the obvious lack of basic airmanship for a moment.

The design problem I see is having a 'convenience' function - retarding the throttles at 27' RA - lead to a situation were the throttles are brought to idle at 2000' without input from the crew because of a faulty RA#1. We don't really need that function on a manual or autopilot flown approach to Cat 1 minimums, so why is it there with the potential to trip up an inattentive crew?

[GearDown&Locked]

I have read all the posts from this thread, and I've kept myself quiet and still at least until some hard facts surfaced from the investigation team. So allow me a quick comment and a simple question.

Something really odd must have happened inside that cockpit during the approach, probably training related with the capt facing away from the instrument panel during those critical 100 secs.

- everyone and the cat have missed important clues from the instruments, namely the discrepancy between radalt readings in both LH and RH PFDs, the speed closing on Vref and not stopping there, etc, nobody saw it
- intercepting and establishing on the G/P is usually the cue for gear down and final flap setting, which prompts the A/T (or the pilot flying manually) to correct speed for the extra drag... didn't happen
- fairly constant airspeed bleeding leads to constant trimming with the pitch increasing to a higher than normal attitude for the config used... nobody noticed it

My question is: at the first stick-shakes would TOGA have brought the A/C out of that RETARD state, or would it be inhibited as well? And would it be feasible given the pre-stall high pitch attitude and the extra pitch up input from the engines at full burn?

GD&L

[Rananim]

If we can disregard the obvious "fly the plane" just for a second and concentrate on the automation issue a bit.The gear warning at 1950' proves they were F5 or worse at 6.5 miles.Probably a speed limitation imposed by ATC.Lets assume they configure right after this to get rid of the warning.Speed would be coming back from F5 speed to Vref 30+5 so initially they would be happy with the TL's idle scenario.Initially.
Lets look at the 2 pilots:
i)TC...lets assume is PM,hes configuring aircraft,talking to ATC,talking his student through the procedure,performing the landing checklist..perhaps he waits to see if the student remembers to call for it,we dont know.He knows the AP is engaged and the localizer and path are captured.He knows the AT is engaged and so to his mind he has minimum speed reversion protection(alpha floor).What has he missed in automation-terms in the "rush"?The top left FMA(AT status) is showing "RETARD" and not "MCP SPD"(GS cap engages AT in this mode).Mode confusion."RETARD" is seen only at 27' on a single CH approach or 24' on a dual CH approch."RETARD" followed by "ARM" is seen in a LVL CHG or VNAV descent from altitude.The picture isnt right but he misses it.
ii)Student pilot..is PF.Hes listening to the running commentary from the instructor,responding to the checklist and supposedly monitoring the automation and flightpath.But what is his scan?A lot of FD fixation and not much else perhaps?Does his scan include the speed tape,the speed trend arrow,the AT status FMA?If it does,and he does attempt to manually increase thrust half-heartedly,the AT computer will fight him and try and retard the levers at 3deg/second.Does he continue to fight it,unaware that all he need do is disconnect it and push them up manually?Does he dare take a command decision like that?Sounds crazy I know but you know what they say about the "meek" inheriting the earth?Can one's own perception of oneself as a lowly trainee reduce you to this level of humility?probably not.More likely that his scan didnt include the speed tape.

When they get the stick-shaker(at 450'?)and are rudely awakened from their total loss of SA,the TC has to react swiftly and fly the stall recovery to perfection to stand any chance.Against him are:
i)startle factor..refusal to accept that this is happening to you..momentary paralysis as seen in Everglades and other crashes
ii)strong pitch-up moment caused by applying full thrust on B737..his target pitch attitude is only 5 degrees and hes fighting a lot of trim and pitch-up moment

The FD BOV mentioned in the initial report relates to system knowledge and should have been a trigger to the distracted TC that things werent right.Unfortunately,this level of detailed knowledge is often buried in the AMM and not the OM....BOV is commonly caused when the master FCC is in LOC and the VHF nav panel is selected to a VOR on the slave side or vice-versa.Pilots will know this.But there are more than a dozen scenarios that cause BOV for pitch and roll and one of them is radar altimeter signal invalid for more than 2 seconds with FD in LOC mode.Does "invalid" mean failure or incorrect reading?Does the software detect a discrepancy beween the 2 RA's and issue the BOV order?I dont know.You wont find that kind of data in the OM.AMM and MEL are very useful sources for detailed systems knowledge.OM skims the surface.

[DingerX]

I'm intrigued by the partial interpretation of evidence (yes, in this thread). First it's an Autoland issue, now some are suggesting that everyone in the cockpit was fixated by a supposed fault.
Which fault was that?

There's an ambiguity in the press release:

The voice recorder has shown that the crew were notified that the left radio altimeter was not
working correctly (via the warning signal “landing gear must go down”).
Provisional data indicates that this signal was not regarded to be a problem.

This can be read in two ways. Many press outlets are taking "notified" in the sense of "made aware" and are stating that the crew knew that the radio altimeter was not working properly. "Notified" can also be used without the implication that the crew correctly interpreted the signal. Hence "this signal was not regarded to be a problem" does not suggest any knowledge of a radio altimeter problem.

Either way, however, the data was discarded, and the crew kept doing what they were doing. There's no suggestion they were chasing some problem other than being behind in a busy environment.

Two other questions come out:
"this problem had occurred twice previously in a similar situation, before landing." This is from the FDR only. What were those approaches like? How's THY maintenance record-keeping in the fifteen years since Valujet 597?

Also somewhere (possibly the press conference), there's the report that, in response to the stick shaker, the FO moved the throttle levers, and then let the A/T move them back again. Huh? Hands off?

In any case, there's no evidence of a crew-distracting "fault". So far as the evidence released to date suggests, the biggest problem in that cockpit was the command gradient. Can some training captains get your attention more than a stick shaker?

[DC-ATE]

Dysag -

Just a question, to help me: do you recall it being written officially that the LH seat man was a "Training Captain" or some equally specific title?
I've searched but don't find such a clear statement.
I don't know how THY is organised, but I wonder about this gentleman's training time, or whether he was mostly a regular line captain.

THAT is the question I asked some time back in this thread. I don't know. Someone wrote that the "Captain" was in the right seat. IF that is so, it is quite possible the "Co-Pilot" in the left seat was in fact a Captain also and merely getting a Line Check.

[BOAC]

My question is: at the first stick-shakes would TOGA have brought the A/C out of that RETARD state,

- yes, and important to get F/D guidance for the g/a too, but NOTHING wrong with click click and straight arm if in doubt!

Yes, the pitch change would have been severe, and may well have caused a subsequent loss of control due to the tailplane trim (see also PGF Airbus thread) particularly if they had re-entered the 700' cloudbase in that state. However, Boeing say they didn't get that far before hitting the ground. Boeing say for some inexplicable reason the A/T was left in and only the throttles 'pushed' open at which point they closed again as designed, causing even more pitch changes.

DC-ATE The RHS TC rumour was introduced awhile back by some erk but has not been substantiated. The official line is TC LHS, F/O trainee RHS.

Dinger - it has NEVER been an autoland problem - just idiots here who cannot read.

Rananim -

nd so to his mind he has minimum speed reversion protection(alpha floor).

- in which case he did not know his a/c!