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Turkish airliner crashes at Schiphol

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Turkish airliner crashes at Schiphol

Old 8th Mar 2009, 08:26
  #1801 (permalink)  
 
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Rainboe's comment was just a demonstration of his pure frustration.

If you erroneously blame the radalt, then you should also erroneously blame:
  • The autopilot, for not being programmed to drop out when below a safe speed.
  • The autothrust, for not having an always-on alpha prot / alpha floor functions, and "Speed speed" callouts.
  • The displays, for not flashing a radalt discrepancy.
  • The dome light, for not flashing when peril is detected.
I have many thousands of hours in both seats of the NG (as well as the 320 series). I find the NG to be crude, nasty to fly, ergonomically challenged and generally a bit incapable during significant non-normals. But it has a saving grace - simultaneously squeeze both thumbs and you are back in a simple aircraft. On numerous occasions when things are going wrong or I think they may go wrong, I have done this and normality has been restored.

What caused the Turkish crew to not do this? I believe that this accident may resemble the Eastern 401 accident in many ways, but not until we hear what is being said on the approach, and in what style, will this become clear. If, for example, one dominant crew member was shouting, then this could have distracted the other two from their flying or monitoring.

What will stop everyone else from doing this in the future? Make sure PF is actually F, and strictly observe stable approach criteria. Our lot make it mandatory to be fully configured at 1000' (in all conditions) and you should be stable. So if the thrust is not up, you are ready to go around. At 500' you must be stable (in all conditions), so if the thrust is not correct or the speed is not correct, then you must go around. Even if the PF was not fully on the case in the Turkish aircraft, then he would still (I hope) have seen that at 1000' the levers were at idle, and would have been watching them like a hawk to check they were up by 500'.
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Old 8th Mar 2009, 08:35
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I always thought having 12000 hours, 6ooo on the ng, the point of having pilots at the front end was to fly the plane or monitor it. it would seem neither were being done.
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Old 8th Mar 2009, 08:38
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Look folks, this forum is opinions only, not final reports. It's well known I will be the first to robustly defend professionals doing their job. There does come a time when the excuses don't really work anymore. We have:
Ask any sim instructor how many times he’s seen a crew distracted so that the aircraft’s flight path is not being properly monitored. I think you will find that it happens frequently when workload is high or something out of the ordinary is happening. The only difference with the Turkish flight was that they had one problem too many on that fateful day.
Like- they had one problem too many- one problem! A minor apparent high approach that got back in the numbers is not a problem. So how are some of you going to excuse flying a serviceable 737 into the ground? Because the RA was down?

Our task here is to feel for an answer. Sometimes a crew come out as unable to alter the course of events. Sometimes we have to accept there are times where the action or inaction of a crew directly or indirectly causes an accident. One could deduce that the failure of the RA and A/T movements 'caused' the accident. One could deduce that because a pilot on final approach did not have a simple thing like a hand on the thrust levers and an elementary ability to scan basic flight instruments, they lost it. How can you blame the system when basic airmanship was entirely absent? So the thrust levers closed. Systems sometimes seemingly misbehave. Hands should be on controls and thrust levers. Pilots have no right to 'rely' on automatics. Maybe its a generation thing, but whenever the system doesn't behave as I want it to, I don't sit there asking why- I hit the disengage button straight away and get back to a human controlling. Younger guys tend to sit there asking 'what's it doing now?'. Like when we once had a full-on TCAS Resolution Advisory. He looks at me for guidance asking 'shall we?' With an alt busting Learjet 400' below us!

The evidence is out. A flyable plane ran out of air. The 'system' is picking up the blame here. The system is just an aid. When the 'aid' is accused of causing the accident, it's absurd. It hurts, but I am prepared to admit the cause was the human element. You can defend and defend, but nobody can deny the simple fact that pilots flew a perfectly flyable plane into the ground. I'm sorry if some of you don't like the words, and abusing me will not help. I'm sorry if it steps on nationalistic toes, that's irrelelvant.

And I am not a Moderator- how does anybody know my posts don't get removed just as much as theirs (they do)?
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Old 8th Mar 2009, 08:40
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it would seem neither were being done.
Indeed, but why? And what system or methodology or rule would help save others from being drawn into the same position. I know we think it can't happen to us, but it has happened.

We need to know why there was no monitoring, so we or others do not fall into the same trap. We all know we can't do it, but I want to know the crew flying my family won't suffer the same mistakes.
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Old 8th Mar 2009, 08:52
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Wow! Once again I awake to this. I will not comment on the main thrust I see above in order to (hopefully) preserve my post.

To try and refocus this thread on what we should really be looking at, I offer the following:

There appears to be an assumption that the loss of speed (back to approach speed) over, say 80 or so of those 100 seconds is not excusable. It is quite likely that the a/c was EXPECTED to be slowing during that time, that the throttles were EXPECTED to be at idle as I suspect the approach had some elements of being unstable early on. Yes, of course, if so the TC should have instigated a g/a or taken control (we do not know yet if he did)

There are 'assumptions' here that the stickshake represented the end of life as we know it and the a/c was 'doomed'. Not so - the stick shake is a warning, and at the time it started the a/c was flying quite 'adequately', and probably following the ILS precisely. No 'horrendous' rates of descent etc. It is at that point that things appear to have completely disintegrated.

There are 'assumptions' that no-one had a hand on the throttles - we just do not know!

Until, as several have said, we have more detail we cannot fully analyse the accident. In my view, however, at the moment there is an urgent need to review several things, including:
1) training and flying ability of airline pilots in general
2) 737 systems and the way they interact and whether some of the bells and whistles are really needed
3) re-emphasis and more training on low speed low level recoveries and upset recovery
4) T Captain 'training' and a reminder of the need to put safety above commercialism.

Please note, although I do consider the TC to be largely to blame based on what I know so far, that is a personal opinion and not substantiated. Reviewing the above does NOT need to depend on my being right.

As others have mentioned, I see an incorrect attempt to recover the stall as the primary reason for the crash. (Oh yes, there will be arguments, but I speak only as a pilot). It appears that whoever initiated it failed to disconnect the 'malfunctioning' autothrottle. The application of a load of thrust at low speed with an aft trimmed tail would result in a huge pitch up force, instinctively requiring a 2-hand push on the stick. At this point the throttles dutifully close again. Loads of forward stick now, big nose up, low speed and now a sudden large pitch down from the change in engine thrust. Presumably another rapid application of power by someone, the a/c rears up again and sinks, now stalled and pretty well uncontrollable, tail first. I do believe that a correctly handled recovery MIGHT have enabled a shaky crew to fly away and have another go.

Could I also endorse the plaintiff and unheeded requests from 'oldbold' for dutytime info too?
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Old 8th Mar 2009, 08:53
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100%please, I think the methodology is to scan your instruments, hand on throttles, scan power settings, be aware of desired power setting, and watch the system. Another way of doing it is to totally rely on the 'system', and get distracted elsewhere whilst you are not watching your basic flying. Then, when you have received a warning that something was very wrong (stickshaker), to not recover adequately. An immediate go-around should have been flown. I cannot think where they were at.

This crew IMO would have recovered the situation despite the defect using one simple technique- hand on throttle below 1000'. It draws power setting into your mind, you will periodically be aware 'why' your hand is there and glance down at the thrust settings. When you push the thrust forward (question: was TOGA hit?), you will be looking for thrust settings. You will glance down, 'is thrust still set, am I exceeding GA thrust?'. The thrust came back to silent! GA was not hit! Nobody noticed. So that acceleration urge and noise petered out, and nobody saw it. Whatever was going on? My comment about the movie duo struck nerves, but why were they so funny? Because one thing after another went wrong- everything they did in the movies was wrong or incompetent. One has to look at the training here, not the system, not the equipment.

Last edited by Rainboe; 8th Mar 2009 at 09:08.
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Old 8th Mar 2009, 08:53
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@Rainboe

Very well said, I fully agree. (#1852)
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Old 8th Mar 2009, 09:08
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100%please, I think the methodology is to scan your instruments, hand on throttles,
Rainboe - of course.

Cast your mind back with me. I remember once as a very junior FO, I had the TC turn to face me and bollock me, screaming, red in the face, for something I had done wrong. I also have a suspicion that the safety pilot with us on the jump seat was probably also not watching the instruments during the tirade.

What I am interested in is why the monitoring wasn't happening in this case.
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Old 8th Mar 2009, 09:14
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Stall recover when fully back-trimed

I'm still curious about Safta's findings. Is it really non-recoverable when fully back-trimed? Anyone tried this in the sim (737NG)? Or even the poor mans sim like FSX (oh, now I risking my life here)

By the way: Does this forum thinks we've switch to daylight saving time? Seems like all new posts are one hour ahead of my clock...

...or is it me that don't know the time?
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Old 8th Mar 2009, 09:18
  #1810 (permalink)  
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Time flies when.................................

I would say it would be recoverable but would require significant care and 'upset' techniques in controlling the nose-up pitch. As I said, a cause for revision of sim upset training scenarios, perhaps? Certainly not a situation I would like (or hope!) to be in.
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Old 8th Mar 2009, 09:18
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bobcat

I think the Brits colonial cousins went "daylight" last night - maybe it's something to do with that
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Old 8th Mar 2009, 09:32
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Instead, after applying full thrust, he had taken his paw off the thrust levers and allowed the still engaged Auto Throttle to retard the thrust levers a second time.
I wonder why. Perhaps he needed two hands on the control column. After all, if the trim was full back, and they were very slow, he probably needed two hands to stop the thing doing a loop.

From that point, this was far from a normal goround and it is quite reasonable to expect that some of the "normal" things like hitting the TOGAs would get missed. It was probably the first thing they knew that anything was amiss! "OH MY GOD!!" would have gone though all three pilots minds. Do you reckon the Captain would have had the wherewithal to say "I say old chap those naughty thrust levers have come back to idle, please reinsert them in the forward-most position as I am fully occupied trying to fly this mother out of the stall with two hands!"? I suspect that at that point, it was "all over red rover" and lambasting the other occupants, especially the safety pilot (probably an FO), for not doing anything, is stretching the friendship a bit. They would have been in total bewilderment.

The captain did one thing right - he didn't flick it. That would have killed everybody.

One suggestion. We have autocalls for all manner of problems. What about one for "Airspeed" when the speed gets to Ref-10 unless the wheels are on the ground?
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Old 8th Mar 2009, 09:44
  #1813 (permalink)  
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What about one for "Airspeed" when the speed gets to Ref-10 unless the wheels are on the ground?
- more importantly what about a call from PM as per SOPs?

A couple of queries for 'safta'

1) you say
the aircraft entered a deep stall as the rudder lost effectiveness
- what does that mean exactly?

2) in both 'failed' attempts, did you follow the Boeing upset procedure for nose high low speed?
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Old 8th Mar 2009, 10:09
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SOP's

I may have missed this. Do the 737NG SOP's require a 1000 ft (AAL) call in IMC for stable engines (i.e. spooling up), or the same at 500 ft if the approach is visual? With TOGA and missed approach immediately if the engines are at idle.

Airbus has these SOP's, and they really help avoid situations involving idle thrust close to the ground. I expect both Turkish Airlines and Boeing have these checks. Confirmation please?
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Old 8th Mar 2009, 10:32
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However we slice and dice this, it all comes back to pilot error.

A/T set up a bad situation do to RA failure?OK, so what.
The aircraft did not meet any logical stabilization criteria on the approach.
Why did a TC allow the approach to continue in IMC if that was the case.
Does THY have mandated stabilization criteria? Do they enforce it?

I can see the report findings now---
A/C was allowed to slow beyond safe flying speed by pilot inattention.
A/C impacted the ground in a stalled state.

Contributing factors- RA1 error resulting in A/T idle of the engines.
Lack of company specific guidance to crew regarding stabilization of aircraft on approach.

At most airlines I have flown at, I would venture to say that this event COULD NOT have happened if pilots followed company policy regarding stabilization. The big culprit here is not the RA or AT. Its the desire to push a bad approach.

For those of you who want to redesign the RA's and AT's. Why not a automatic pull up and TOGA on a GPWS warning,just incase the pilot would be too distracted to do it himself
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Old 8th Mar 2009, 11:09
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As it stands it looks pretty bad for the crew.
We still don't have all the info and I can imagine scenarios that make it less damning
for the crew.
For example, if the speed was decaying as expected while configuring then the thrust levers would be where they were expected to be. If the training captain suffered from a subtle incapacitation between 2000ft and 700ft then I can see how a new/inexperienced F/O could be distracted enough to miss the airspeed dropping through VRef as he figured out what was going on with the TC.
I'm not suggesting that this is a likely scenario, but it is not impossible, and at this stage we simply don't know.
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Old 8th Mar 2009, 11:15
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Turkish airliner crashes at Schiphol

If the Stabilizer trim was indeed trimmed almost fully nose up ( preparing to land), then to recover from stick shaker, the aircraft would have to be leveled off and full power applied.
If full power was applied with full nose up trim, the aircraft will, most likely,
pitch to the pitch limit indicator (PLI) and enter a secondary stall. At this low altitude with full nose up trim and very low airspeed, it would be extremely difficult to get out of this situation in time.
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Old 8th Mar 2009, 11:18
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I think there are two threads here. There's the questions for the report - complex interactions between systems and pilots.

Then there's the 'keep it simple stupid' of not letting it happen to you.

PF must fly the aircraft at all times!! Simple as that. If the autopilot's engaged on the approach you should still be covering the controls and scanning the instruments as you would on a manual approach.

What I see an awful lot of when training people is that PF feels he/she is not doing enough if they are 'simply' flying the aircraft. There's an almost guilty need to be seen to be doing more.

But give the PF a slight distraction as the autopilot is levelling off, and there's a good chance they'll bust their altitude. Why? Because they're not actually flying the aircraft!! Ask any trainer worth their salt.

Next time you're PF, have a good honest look at how often you're not actively flying the aircraft and then think about this thread.

Looking to a wider perspective, I think there can be problems with the emphasis on systems knowledge over good old fashioned airmanship and CRM in type training. I've experienced over zealous trainers showing off their own technical skills and perhaps nit-picking when pilots fly 'ugly' but safely, ie, not using the automatics in the sophisticated way they'd like.

I'm not for a moment saying systems knowledge isn't important, but we have to be clear where it lies in our list of priorities, given that there is only ever a finite time to be spent on training.

The thing I hear myself saying over and over in the sim is 'just fly the thing'. I think we need a re-emphasis on the basics.

I'll admit at times when I've moved to a new type that my technical knowledge of the systems has not been what I'd like it to be. But I've felt confident in my safety because I know it's still just an aeroplane that conforms to some very basic laws of physics like all others.

Fly the aeroplane.

Last edited by Maximum; 8th Mar 2009 at 11:29.
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Old 8th Mar 2009, 11:33
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One suggestion. We have autocalls for all manner of problems. What about one for "Airspeed" when the speed gets to Ref-10 unless the wheels are on the ground?
Capn, thats part of the the problem, the wheels WERE on the ground! A bit below actually... (according to the RA)

Question to the 737 pilots: are the RA antennas about 7-8 feet above the ground?
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Old 8th Mar 2009, 11:42
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Unhappy

BOAC

Bloggs suggestion was for an automated callout at Vref-10 as a fail safe, not as a replacement for SOPs.

It seems reasonably safe to conclude that no one in the flight deck detected the airspeed decay before the failsafe warnings activated - hence no SOP calls. This accident is a reminder of all the things that could never happen to us - right? The message on what distractions were present will have to wait until the final report, but the time to seriously look in the mirror is now!

Bloggs

While playing with UAs the other day in a different type, ended up with a nose high and subsequent stall due to undetected full nose up trim - recovered after retrimming but highly doubt we would have stayed upright in the aircraft as long as we did in the sim before noticing the trim. We had both pilots holding full forward stick and could not get lower than 10 NU - at altitude, we had insufficient thrust to prevent the stall at that attitude.

Very sobering in that I have not previously included trim in my UA recovery plan. However, unlike some previous posts, I would never consider trim as a means of changing the attitude, only as a way of ensuring that adequate elevator response was available.

Stuntpilot

Weight on wheels AND Rad Alt?
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