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Turkish airliner crashes at Schiphol

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Turkish airliner crashes at Schiphol

Old 5th Mar 2009, 20:28
  #1421 (permalink)  
 
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737Jock

increasingly higher pitch attitude, less noise (wind and thrust), speed entering yellow band on speed tape, speed entering red band, stick shaker!
Also the trim wheel noise (already mentioned) and the pitch limit bars are real attention grabbers.

bullet190

lack of basic flying skill.
To all those who mention hand flying skills, I don't think an F4 jock would lack those skills

airbus a330

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
I have suffered this kind of so called CRM and would not have kept my mouth shut with increasingly higher pitch attitude, less noise (wind and thrust), speed entering yellow band on speed tape, approaching pitch limit bars ...

whoever wrote it
A more experienced 737 'pilot flying' would I believe have had the gear down and been busy configuring before the localiser intercept.
From AMS airport briefing: Select gear down after passing 2000'

@rainboe:
a 737 only fits three in the cockpit - as you seem to not know...
Maybe it does (since I'm used to some kind of CRM as I said b4, note that I prudently said maybe )

BOAC

- in which case he did not know his a/c!
I wonder how many -besides you- knew off the top of their head that the A/T system relied entirely on nș1 RA.


misd-again

Gods of the Glass". Automation is the answer.... Heaven help us if the glass fogs over.
Well automation has its own problems (as this accident reminds us once more) but may we agree that it has made aviation safer?

AfricanSkies

1) assuming the A/P was also left engaged, would we get the flare/retard sequence? Given that the flare does not arm by 350' and is thus unavailable during normal 1-ch approaches I have previously done, I think not...
Besides Rainboe last answer somebody previously mentioned, citing the AMM, that the flare feature is built in the A/P and is available Single Channel though unannounced.

I think something that has nothing to do with flying skills, went very wrong in that cockpit.

I personally don't like:

- Getting RETARD on Single Channel approaches

- No RA disagree warning, just as there is a Baro altimeter disagree warning, on a multi million $ plane when it can have such dangerous consequences (an untimely retard during approach looks dangerous enough to me to spend a few bucks on such a device)
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Old 5th Mar 2009, 20:31
  #1422 (permalink)  
 
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..and perhaps as they broke cloud, and pitch up was already underway, all 3 were squinting in the wrong place on the windscreen.....
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Old 5th Mar 2009, 20:39
  #1423 (permalink)  
 
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As a very low time SPL holder, who's flown only under VFR using nothing but dead reckoning, I've always come here to absorb as much as I could from the pros, so as to improve my changes of not screwing up, especially when upgrading to a PPL/IR (hopefully in the very near future). Hence, it's always been my policy not to post anything unless I could make a useful contribution or had a relevant question.

Having read every post in this thread (and deeply sympathizing with those becoming aggravated by the constant repetition of questions and facts), it seems to me that a major theme here is the complacency brought about by automation and loss of basic airmanship skills, particularly among a newer geneation of pilots (something also discussed in the context of the Colgan accident). Considering the advent of ab initio training programs, maybe this is something that will need to be more carefully looked into.

In this regard, I'd be interested in hearing your opinions about the use of head-up displays, an option now for the 737NG. I'm by no means trying to advocate another system layer or automation as a substitute for better training and airmanship skills. A good instrument scan would have prevented this accident. But many have pointed at deficiencies in modern training, not to mention human fallibility. As Rainboe just said, even though it shouldn't happen, all eyes tend to fixate outside when you break out of clouds. In that case, you'd be better off looking through something that gives you some information.

On the other hand, I'm not sure having only one HUD (capt. side) would have made a difference in this case as he was the PNF and could have had his eyes on a checklist. Moreover, I could also see HUDs leading to more complacency, with pilots failing to monitor other instruments (e.g. EICAS). But this is why I thought I'd ask your opinions.

@lakerman (#1392):

Like you and after all that had been discussed on this thread, I was appalled by Avweb's newsflash containing, among other things, this pearl: "The autopilot initiated a power-down of the engines (...)."
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Old 5th Mar 2009, 20:43
  #1424 (permalink)  
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ant1 - my comment was regarding the LACK of min speed reversion on a coupled ILS which he SHOULD have known as a TC. Please re-read my comments about the implications of the radalt failure/GPWS (currently at 1344)
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Old 5th Mar 2009, 20:44
  #1425 (permalink)  
 
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Has there been any statement regarding the quality of the Cockpit Voice Recorder recording ?

.
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Old 5th Mar 2009, 20:46
  #1426 (permalink)  
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SoarngTheSkies;
The 767, however, has three independent pitot systems, right? (two for the CPT/FO PFDs and one feeding the Backup). So while a sinlge pitot/static, if it fails without any backup, will create a major issue, having three of them will always render the failed one a minority.
Yes, correct but not easily discerned in all cases - sometimes one must switch pitot-static sources manually. In our case, the PF's airspeed was increasing while mine (the PNF) was decreasing as he "tried to keep the speed below VMO", 340kts I think, anyway it was close to red-lining. I called out my airspeed which was by then around 220kts (climbing through 240 or so). We compared both CAS's with the Standby and decided mine was correct so I took control. Interestinlgy, the altimeters were not affected. The system recovered on approach at the other end, in warmer air. We had a number of EICAS messages regarding the rudder limiter and something about aileron control but no overspeed warning when the PF's CAS exceeded VMO.

The same would apply in the 320/340 series I think but again, pitot-static sources may have to be selected - I'd have to examine the books.
In that case it's at least rather trivial to determine that they are in disagreement and thus not trustworthy. If you then also look at altitude trends from the barometric altimeter, you'd again be able to rule out the faulty one.
Precisely. And today, given the installation and a few moments to bring up the appropriate FMC page, one can use the GPS altitude and groundspeed to keep things perhaps not to the foot or knot, at least within the nominal.

This is a very, very sad accident among sad accidents.
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Old 5th Mar 2009, 20:52
  #1427 (permalink)  
 
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"Boeing said the autopilot system is designed so that if it senses faulty data from the captain's altimeter on the left side, the autopilot, including the autothrottle system that controls engine thrust, is supposed to switch to the altimeter on the right side used by the co-pilot. Boeing would not comment about what may have gone wrong on the Turkish jet, saying that is part of the investigation."

Seattle Post Intelligencer writes the above cited. Sheds a completely new light on the A/T system logic. The link to the complete article:

Faulty altimeter led to 737 crash in Amsterdam
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Old 5th Mar 2009, 20:55
  #1428 (permalink)  
 
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recovery...

-hi mate! as you are sending me "back" to the sim for practice (which I always enjoy and find profitable), may I send you back to aerodynamics basic courses and common sense ?
-D-EAS curve ; position of this acft on it at 500ft ; recovery in landing configuration AFTER recovery from the TOTAL loss of sit.awareness...eventual change of PNF to PF for the LTC , planet earth coming fast to embrass you etc...Can you try to put yourself at this place and think for a moment maybe ? And just stop about thinking about your sim a bit, where you just expect the shaker with your hands ready for the perfect recovery...
-I'm sure you are just kidding me while you say that this stick shaker recovery is feasable. Well, guess what, the facts just seem to proove that it's not ! Not after this total and long loss of SA.
-Sorry to say again, but the tragic end was written well before the shaker.
-How come NOBODY was flying the plane ? That's the question but we are far from an answer I'm afraid !

flyer146

P.S : someone talked about AVRO/BOEING comparison. Do not forget that the English were the first to manage the Autolands years ago, what ? due to the weather in UK ? might be yes ! Still the AVRO is much more advanced in this technology than the Boeing, I've flown both, not to be compared ! (in this particular area of course...).
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Old 5th Mar 2009, 21:02
  #1429 (permalink)  
 
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Dutch SAfety Board

Dutch Safety Board issues warning: Malfunctioning altimeter caused THY 737 autopilot to decelerate.
Thursday March 5, 2009.
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Old 5th Mar 2009, 21:08
  #1430 (permalink)  
 
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FE Hoppy Wrote: I was a little surprised by the initial report. Not what it said but the way it said it. I seems to be written in a deliberately none technical manner. The AT mode being wrongly called flare and a lack of real data other than a couple of heights and speeds. Very different to for example a UK AAIB report.
Well maybe that is because it is not a report! It is a press statement!
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Old 5th Mar 2009, 21:17
  #1431 (permalink)  
 
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PJ2

Interestinlgy, the altimeters were not affected.
in that case I would suggest it was not the static but the pitot tube itself. That was the case with the Birgenair flight. As they climbed, the static pressure decreased, however, the pressure inside the clogged pitot tube remained largely constant. A higher pressure differential between pitot and static is interpreted as higher airspeed, therefore, the automatic systems pitched up and reduced thrust right into the stall. To make things worse, the crew thought that the stickshaker was really an overspeed effect, with the CPT PFD speed reading way up there. All the time, the backup and the FO airspeed was correct.

A blocked static should have the opposite effect: the higher you climb, the smaller the pressure differential as static pressure remains largely constant (maybe even to the point where static pressure becomes larger than pitot pressure).

I guess we don't disagree much. We're just looking at different areas of potential improvement. It's the swiss cheese model all over again. The hole that represents a radalt failure may be tiny, but in this case, it was perfectly aligned with a number of others. We're just moving different slices ;-) (and all the time hoping that we're not aligning other holes as a result).

Thanks for the interesting discussion.
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Old 5th Mar 2009, 21:29
  #1432 (permalink)  
 
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before we all get too hung up on the automation and bergenair etc. remember that we do need pitot static systems to fly an aircraft in IMC - and failure of this system will always be a problem - possibly manageable but an issue nonetheless. we do not need autopilots and rad-alts to fly an approach, sure they're a nice-to-have but not essential and failures should be complete non-events. The fact that this wasn't a non event is not an automation, or Rad-alt logic etc etc etc issue, it was human factors issue.
This minor (and it was VERY minor) failure should not have led to this accident. either there is some other problem that the press briefing (note as mentioned above, this isn't a report its a press breifing) hasn't mentioned, or there is a human factors issue that we can all learn from - although its probably going to come back to Aviate-navigate-communicate.
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Old 5th Mar 2009, 21:44
  #1433 (permalink)  
 
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I agree with africanskies,

The majority of approaches I fly are handflown. Once in a while, when the weather is close to cat 1 minima I fly it sinle A/P with A/T until DH and then disconnect. Very rarely I fly a dual A/P approach.

I for one thought as well that the retard function of the A/T was only available during a dual A/P approach. I know now better!

Having immediatly dug out the manuals, nothing in there indicates that the retard funtion of the A/T is also available during a sinle A/P app. even worse, nowhere in my boeing manual it states that the A/T derives it altitude signal from the left RA (please, I looked, if someone has found were it states that let me know),

Having said that, the lack of that knowledge does not relieve one of flying the plane. The fact that the A/T commanded idle thrust at that point is something one would normally expect anyways, you intercept the G/S, command gear down, flaps 15 and set f15 speed or 160 ( depending on sop) and then getting close to 160 or F15 speed to call for flaps 30 set fas. Even disregarding the FMA annunciations one would expect when the speed approaches fas the A/T to increase thrust. monitoring speed at that point during the app is pretty basic.

What if after G/S intercept and the A/T moving to idle the A/T for some inexplicable reason had clicked of, the same would have happened in this case. Why? The pilots where not monitoring the instruments.

Simple in this case, the automation did something unexpected and the pilots did not catch it.

I for one learned some valuable lessons. For one I thought the retard funtion of the A/T was only available during a dual A/P approach and even with hindsight the boeing books don't indicate otherwise.

the argument used a few post back:what would you expect it to do, maintain mcp speed until touchdown. Frankly, that's exactly what I would have expected because boeing doesn't want you to leave it engaged until touchdown on a single A/P approach. that some hero pilots knew better because they tried it in the sim, well, [email protected] to them. The normal line pilot doesn't know this because it's not in any boeing approved training program. Seriously,I would like to have a show off hands of the number of pilots that knew this! and then my next question: if you are flying enroute and the left RA would have a hickup and indicate -8 would the A/T go in retard mode as well or does this only happen after G/S intercept. I can't get this out of the manual neither!!

The normal line pilot should however know to monitor basic instruments.

Anyways, now we know what happened. The only interesting thing left is why? Why did 3 experienced pilots fail to realise that the airspeed dropped 40 kts below ref.

Last edited by flyburg; 5th Mar 2009 at 21:55.
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Old 5th Mar 2009, 21:59
  #1434 (permalink)  
 
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Flyer146

-hi mate! as you are sending me "back" to the sim for practice (which I always enjoy and find profitable), may I send you back to aerodynamics basic courses and common sense ?
-D-EAS curve ; position of this acft on it at 500ft ; recovery in landing configuration AFTER recovery from the TOTAL loss of sit.awareness...eventual change of PNF to PF for the LTC , planet earth coming fast to embrass you etc...Can you try to put yourself at this place and think for a moment maybe ? And just stop about thinking about your sim a bit, where you just expect the shaker with your hands ready for the perfect recovery...
-I'm sure you are just kidding me while you say that this stick shaker recovery is feasable. Well, guess what, the facts just seem to proove that it's not ! Not after this total and long loss of SA.
-Sorry to say again, but the tragic end was written well before the shaker.
-How come NOBODY was flying the plane ? That's the question but we are far from an answer I'm afraid !
Will be doing perf on monday. Oh wait I'm teaching!!!! I'm pretty familiar with drag curves power curves and stick shakers but I'll do a little revision as it never hurts.

We are actually arguing the same point but with different emphasis. Of course this incident didn't start at the shaker. In a perfect world the speed should have been noticed well before. In my last post I gave an Altitude and Distance from threshold where the aircraft went through Vref.(approximations based on ADS-B confirmed by the report)

What I do disagree with is that the aircraft could not be recovered from the stick shaker point. The reason it wasn't will come out in the first report as this press statement doesn't give details.

On a current Type Rating Course near you for an aeroplane of similar configuration but lower mass they include stall recoveries in session 1. Both clean and in the landing configuration. In the latter case they include from level deceleration and whilst following a 3 degree path. The rate of deceleration to the shaker is similar to this case. YES, you are completely correct that the students are pre-briefed and expecting it and are completely (not sure in all cases) aware of what is about to happen. The point is, It is recoverable with minimum or no height loss. The THY crew had 500' to swap for speed. They had plenty of thrust available. They must have trained this on their Type rating course.

What I'm trying to say is that an average crew on an average day should be able to recover from a shaker at 500' when configured.

This crew obviously didn't manage. For me the most important information to come out of the final report would be why they were unable to recover. That is one of the areas where some serious lessons will be learned.

Not trying to start a fight mate, there are too many of those on here already.
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Old 5th Mar 2009, 22:24
  #1435 (permalink)  
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SoaringTheSkies;
in that case I would suggest it was not the static but the pitot tube itself.
Yes, that's what we figured too. It was a dirty winter night so we weren't turning back...we hand-flew it across the country on manual everything.

Its encouraging to know we're looking at the same animal. Agree - a tiny hole, as were the Congonhas A320 and Madrid MD83 accidents.

Yes, great discussion/sidebar, thanks as well.
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Old 5th Mar 2009, 22:26
  #1436 (permalink)  
 
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ant1 - agreed, the increased capabilities of automation has made it much safer.

Airplanes routinuely use RNP/RNAV/FMC approaches into mountainous terrain. EGPWS w/FMC's is priceless, but it has to be backed up with basic situational awareness and the ability to fly the airplane without all the fancy toys.

Knowing when to use, or not use, automation is key. That's where the "Gods of the Glass" comes from - the blind reliance on the 'glass'(ie automation/magic) to save them, as opposed to HOTAS(Hands On Throttles And Stick).
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Old 5th Mar 2009, 22:26
  #1437 (permalink)  
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Last edited by Rainboe; 17th May 2009 at 21:57.
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Old 5th Mar 2009, 22:31
  #1438 (permalink)  
 
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from 2000' - the a/c would start to be reconfigured from a low drag, 180kt config to landing Flap.. Not normally a problem with the automatics in... the 'training' F/O in the RHS - possibly a little behind the drag curve - will be calling for the flap changes which the Cpt will be selecting.. at the same time no doubt - approach will be instructing a change over to Tower requiring frequency tuning (heads in)- so quite a high workload even for the trainer (who's also supposed to be watching what his trainee is doing !)
The 'faulty' RAD ALT problem at 2000' sends the A/T into 'retard' but could easily go un-noticed as T/Ls would be at idle anyway, as speed reducing.. (Not sure when the 'nuisance' GPWS alerts came - but these would just add to the confusion.)

F/O possibly becoming more and more maxed out - poor scan rate, probably concentrating on looking out for first visual clues of RWY (i remember being there !) - Should have his hand on T/Ls - but hasn't - not picked up by busy T/Cpt..
As final Flap (30?) has been reached - thrust levers fail to advance but this isn't immediately picked up by the F/O. Cpt possibly distracted by contacting tower - maybe heads in dialing up the ground freq - (i can never remember which one, so maybe he has to look at the chart!)

Speed has quickly decayed but still IMC so the increase in attitude not so obvious - the lack of noise possibly masked by GPWS noise.. as the stick shaker goes off Cpt takes control and advances T/Ls - (A/P disengaged but forgets to take the A/T out - ok we can all do it ok in the Sim, but you only have to read how many G/As are poorly handled these days.. & this is after a stick shaker ) Uses both hands on control column due to the high forces involved.. 'inexplicably' - the thrust levers 'retard' again - which none of us would expect.. before he realises it's too late....

Some posters have correctly stated that there are certian situations when training must simply stop - but these can creep up on you very quickly... it's easy to blame the crew for lack of monitoring, and in fairness they should have done better - one does wonder what the third crew member especially was doing - if, in deed he was there as a 'safety pilot'..
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Old 5th Mar 2009, 22:50
  #1439 (permalink)  
 
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With respect, a slight disagreement.
I did note that the minimum speed mentioned matches the ADS-B data so if I look at the ADS-B trace and consider "landing speed" as quoted in the report to mean Vref then they were at Vref at about 900ft and 2.5D.
My trace at 2.5D shows 800 ft and 130 kts GS, or ~145 kts IAS assuming a surface wind of 10 kts. Perhaps hair splitting, but might have significance.

...

..and perhaps as they broke cloud, and pitch up was already underway, all 3 were squinting in the wrong place on the windscreen.....
The thought crossed my mind too
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Old 5th Mar 2009, 23:05
  #1440 (permalink)  
 
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BOAC: #1344 read and hopefully understood

Where did you get the
LACK of min speed reversion on a coupled ILS
All I can find is:

- engagement of GS capture automatically engages the A/T in the MCP SPD mode.

- alpha floor automatically engages the A/T when armed

misd-agin: I agree, and I am almost sure the crew knew that, too. A sad turn of events, whatever the implication of the crew will be at the end of the enquiry.

Last edited by ant1; 5th Mar 2009 at 23:16.
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