Turkish airliner crashes at Schiphol
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Semaphore Sam - yes I would judge your comment to be pre-mature, premature too.
Tee Emm - Point taken. I meant of course the likelihood that if they were a little fast then the PL's were probably already at idle when RA#1 malfunctioned to command RETARD and that the crew fully expected the A/T would restore thrust at the appropriate time but failed to monitor. The idea of installing some form of stabilised approach criteria monitor alarm or warning would be to pick that up and alert the crew. I know in my case the guilt of knowing I am often a little faster than stabilized criteria might allow, has me keep a good grip on the PL's while eyeballing the airspeed intently, willing it to decrease so that I can restore thrust to its proper value. But then I don't have the luxury of A/T to do that for me which tends to concentrate the mind.
Wizofoz - I too am leary of adding yet more automation and I agree with all your points about SOP's and training and the culture of flying with automatics. But the plain fact is that adherence to stabilized approach criteria would have saved the day in this instance, but they are not being enforced precisely because application is left to the pilots discretion. Perhaps the flying public deserve a better standard of compliance with stabilized approach criteria than we have been able to effect to date and if such a warning system were devised I tend to believe that pilots would fear its intrusion rather than rely on it in the same way that controllers are wary of the snitch patch. It's gonna mess up the arrival rates at the busier airports but them's the breaks.
Tee Emm - Point taken. I meant of course the likelihood that if they were a little fast then the PL's were probably already at idle when RA#1 malfunctioned to command RETARD and that the crew fully expected the A/T would restore thrust at the appropriate time but failed to monitor. The idea of installing some form of stabilised approach criteria monitor alarm or warning would be to pick that up and alert the crew. I know in my case the guilt of knowing I am often a little faster than stabilized criteria might allow, has me keep a good grip on the PL's while eyeballing the airspeed intently, willing it to decrease so that I can restore thrust to its proper value. But then I don't have the luxury of A/T to do that for me which tends to concentrate the mind.
Wizofoz - I too am leary of adding yet more automation and I agree with all your points about SOP's and training and the culture of flying with automatics. But the plain fact is that adherence to stabilized approach criteria would have saved the day in this instance, but they are not being enforced precisely because application is left to the pilots discretion. Perhaps the flying public deserve a better standard of compliance with stabilized approach criteria than we have been able to effect to date and if such a warning system were devised I tend to believe that pilots would fear its intrusion rather than rely on it in the same way that controllers are wary of the snitch patch. It's gonna mess up the arrival rates at the busier airports but them's the breaks.
Last edited by MU3001A; 11th Mar 2009 at 05:02.
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GlueBall:
I know. I was just answering Rainboes comment "Controllers do not fly or tell the pilot how to fly". Well, they does... Sometimes... When a MSAW alerts goes off. Wouldn't surprise me if MSSW (for speed) appears. Of course a lot more sophisticated then MSAW because minimum speed is not an absolute number.
The next plan I will fly has Vs = 35 knots. (!!) Yes, thirty five.
This warning does not apply to decaying airspeed or ground speed
The next plan I will fly has Vs = 35 knots. (!!) Yes, thirty five.
In which way did the TCAS contribute to this accident? As I understood it they would have been fine if the Tupolev had followed the RA.
But EQUALLY true that if NEITHER had had TCAS and BOTH had followed ATC instructions, it would also have been avoided.
It's a prime example of how simply introducing a new magic box does nothing to improve saftey, and can be detrimental if it is not universally used correctly.
This accident is a case in point. Would it have happened if the AC hadn't HAD an autothrottle?
MU, agree entirely about stabilised approach criteria, but a rock solid culture of SOP adherence, total non-sanction (indeed, make it non-reportable) for a go-around due not being stable, and arse-kicking-to-follow if you press on works just as well as a new GPWS warning. People are capable of ignoring those too!
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Faulty altimeter, thust levers commanded to RETARD and subsequent stall seems to be the consensus.
Following the RETARD mode the A/T reverts to ARM unless disengaged by man or machine. Input from the air/ground sensor would cause the A/T to disengage 2 secs after touchdown, otherwise with the automatics engaged the A/T reverts to ARM, and with the speed still decaying the AFS pitches the nose down if the thrust levers are not moved.
Should you initiate a go-around by pressing TO/GA, the automatics disengage unless in a dual channel mode(not the case). Was there a mode confusion if a G/A was initiated?
So we need to know if the A/T was engaged at all in the first place.
There was an incident couple of years ago where a crew tried to circle of an ILS with the automatics in,the APP mode was exited by disengaging the automatics, however being too busy ''in and out'' the crew forgot to re-engage the A/T and subsequently reached the middle of yellow band but luckily recovered just in time.
There was a case also involving a 74 operation where the PM becomes PF at minima, who then as as he took over initiated a go-around without advancing the thrust levers. Speed decayed but was spotted in time.
Human has to know,monitor,respect and care for machine. Otherwise its a ''Garbage in garbage out'' outcome no matter how automated the automatics get.
Following the RETARD mode the A/T reverts to ARM unless disengaged by man or machine. Input from the air/ground sensor would cause the A/T to disengage 2 secs after touchdown, otherwise with the automatics engaged the A/T reverts to ARM, and with the speed still decaying the AFS pitches the nose down if the thrust levers are not moved.
Should you initiate a go-around by pressing TO/GA, the automatics disengage unless in a dual channel mode(not the case). Was there a mode confusion if a G/A was initiated?
So we need to know if the A/T was engaged at all in the first place.
There was an incident couple of years ago where a crew tried to circle of an ILS with the automatics in,the APP mode was exited by disengaging the automatics, however being too busy ''in and out'' the crew forgot to re-engage the A/T and subsequently reached the middle of yellow band but luckily recovered just in time.
There was a case also involving a 74 operation where the PM becomes PF at minima, who then as as he took over initiated a go-around without advancing the thrust levers. Speed decayed but was spotted in time.
Human has to know,monitor,respect and care for machine. Otherwise its a ''Garbage in garbage out'' outcome no matter how automated the automatics get.
Last edited by airbusa330; 11th Mar 2009 at 06:43.
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''Lawyers of the passengers(and relatives of victims) now consulting Lawfirm Speiser, Krause Madole & Lear in New York for further legal action''
Lawyers know exactly what and why it happened. Maybe it was them that advised Boeing on what not include in the operations manuals in the first place. Why don't they tell us then?
Lets wait for the transcript/investigation/conclusion. And at least the truth will be known. One positive out of a really sad event. Without sounding and touching a raw nerve, had it happened at home we would have never known as to the true cause. Neither did Lawyers for Aeroflot Flt 539 find anything wrong with children occupying a control seat.
Lawyers are only worried about their cut out of all this, like vultures on a carcass.
Lawyers know exactly what and why it happened. Maybe it was them that advised Boeing on what not include in the operations manuals in the first place. Why don't they tell us then?
Lets wait for the transcript/investigation/conclusion. And at least the truth will be known. One positive out of a really sad event. Without sounding and touching a raw nerve, had it happened at home we would have never known as to the true cause. Neither did Lawyers for Aeroflot Flt 539 find anything wrong with children occupying a control seat.
Lawyers are only worried about their cut out of all this, like vultures on a carcass.
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Originally Posted by PJ2
But when we beat the aircraft, we beat ourselves; - the metal doesn't care and will do it again just as soon as it can.
)=====
FOQA ? Do Turkish operate such a scheme... sure it would have been mentioned * This would be one way of picking up continual approach busts, poor monitoring as well as that RA persistent failure.
If not, should ? now be thinking along the lines of enforcing such schemes in at least all European airlines above a certain size?
if there are 'cultural problem' airlines, would it not help get around that, the challenge coming from management or more dispassionate QA analysts with a stronger mandate (OK, I'll get shot for suggesting FO, SO hasn't the 'strongest mandate', so bullet proof vest on, but YUKWIM)
*YES, I've read every post, at some point
Last edited by HarryMann; 11th Mar 2009 at 10:50.
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Everybody is talking about the faulty radio altimeter as it is the main reason for the crash. 
The main reason are the 3 pilots in the cockpit. They didn't check their basic flying instruments and didn't fly the aircraft. How is it possible that a "well" trained capt and 2 FO's didn't see that that the thrustlevers were at iddle for more than 100sec
and that the speed was dropped to 40 kts below it's target ???? During the approach, you are supposed to concentrate on the instruments and on flying the aircraft (even if it is doing an autoland)
The reason for me : very bad CRM and very poor flying qualities.
I did some flying in Turkey and I was not at all impressed by their qualities. Most pilots are ex-Military and they are still using their grades. This is Major X, this is Col Y. In the cockpit, most Captains think they are God and don't accept any input from the FO. A Captain was (without joking) calling a FO, the "Flap Operator". This is cultural and it's very difficult to change this.
The same happens at many other Middle-East companies. CRM, CRM, CRM !!!
The main reason are the 3 pilots in the cockpit. They didn't check their basic flying instruments and didn't fly the aircraft. How is it possible that a "well" trained capt and 2 FO's didn't see that that the thrustlevers were at iddle for more than 100sec
and that the speed was dropped to 40 kts below it's target ???? During the approach, you are supposed to concentrate on the instruments and on flying the aircraft (even if it is doing an autoland)The reason for me : very bad CRM and very poor flying qualities.
I did some flying in Turkey and I was not at all impressed by their qualities. Most pilots are ex-Military and they are still using their grades. This is Major X, this is Col Y. In the cockpit, most Captains think they are God and don't accept any input from the FO. A Captain was (without joking) calling a FO, the "Flap Operator". This is cultural and it's very difficult to change this.
The same happens at many other Middle-East companies. CRM, CRM, CRM !!!
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Originally Posted by EXCIM
How is it possible that a "well" trained capt and 2 FO's didn't see that that the thrustlevers were at idle for more than 100sec
CRM, CRM, CRM...
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Tee Em, that's what I think, too regarding the unstable approach issue.
I think we can easily agree that under the current state of the art in commercial aviation, HAL (AKA George) initiating a go around on it's own is not desirable.
The RA comparator issue would be more in the Boeing's (KISS) philosophy.
Again, not on GS, it's more like the A/T if ARMED will move forward due to alpha floor.
I think we can easily agree that under the current state of the art in commercial aviation, HAL (AKA George) initiating a go around on it's own is not desirable.
The RA comparator issue would be more in the Boeing's (KISS) philosophy.
and with the speed still decaying the AFS pitches the nose down if the thrust levers are not moved
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Moderators are busy removing the untold rubbish and the crass stupidity that pervades this thread. It is better to THINK VERY CAREFULLY about what you write before pressing the submit button.
It really is getting tiresome - we are beginning to hear the echoes of ear splitting repetition!
Edit: Actually, it is hardly likely that anyone could add anything further to this thread that has NOT been said and repeated many times already - the CVR chat would help a lot though.
Oh! And while you might think you can use PPRuNe for a post chat - please don't - join MSN or such and don't waste our time.
It really is getting tiresome - we are beginning to hear the echoes of ear splitting repetition!
Edit: Actually, it is hardly likely that anyone could add anything further to this thread that has NOT been said and repeated many times already - the CVR chat would help a lot though.
Oh! And while you might think you can use PPRuNe for a post chat - please don't - join MSN or such and don't waste our time.
HarryMann;
It was Basil Fawlty with a small shrubbery in hand swiftly beating his little car that I had in mind... and the thread itself deserves nothing less.
Yes, I know precisely what you mean and have written about here dozens of times - Flight Operations is not concerned with flight safety. It is concerned with making money. While there are tiny pockets of resistance among enlightened airlines and their managements, the flight safety department is generally found far away from the main buildings, "down the hall, to the right...etc", an untidy, under-resourced backwater, a "senate-seat" for formerly ambitious men (strangely, no women), who were unfortunate enough to pxss in the cornflakes of someone above them on the way up or they had the temerity and courage to speak the truth at corporate safety meetings and challenge others' performance and statistics as reported by safety programs doing the job of providing data.
The descent, since the sixties, of the curve showing the fatal accident rate, now at an all-time low, is about to start climbing again. The Turkish accident is merely the latest canary in the mine. Too many who lead in government and corporate offices are comfortably numb or paralyzed by present economic difficulties. SMS means someone in middle management must stick his/her head above the trench and call an operation because of a crew's "difficulties with the MEL...etc, etc" and that will be the end of that person's career advancement. You can't put someone who is responsible for the bottom line, in charge of safety processes and decisions.
FOQA at Turkish? At a number of safety conferences I have met and discussed FOQA programs with both western and eastern European airline safety representatives. While intentions of many are earnest, FOQA struggles to survive because of bean-counter ignorance and short-term thinking/planning. I spoke with no one from Turkey but given the public statements in Hurriyet ostensibly expressing denial of what really happened to their aircraft I would not be the least surprised if no FOQA Program existed at THY but I don't know. I'm sure someone will correct me if THY has a FOQA Program, (in which case I have some questions for them).
The corporate ignorance (and increasingly, government ignorance as governments get out of the safety business and hand it over to private corporations), of how the industry has achieved the excellent safety record it enjoys today, is increasing, partly due to lost history/experience, but mainly due to the new politics of safety. Such collective ignorance is tacitly granting permission to airline managements to set aside flight data programs which inconveniently show that not everything is well. This isn't just an opinion or reading about others' experience in trying to breath life into data programs.
One last thing...if we need a bullet-proof vest for raising notions such as the focus and first priority of FO, then my point is made. In my experience this is half the reason why SMS, an excellent concept, will fail in reality; no leadership, reduced to nil regulatory oversight - the FAA/Southwest/American/United events are cases in point.
These days, robust safety programs and processes take too much of the bottom line. Perhaps airline managements have set aside "corporate ethics", (an oxymoron if there ever was one), and are under the illusion that it is cheaper to buy the insurance? Regardless, for those who understand aviation and the fundamentals that keep it safe, the dynamics are clear. Fatal loss of control accidents are matching CFIT accidents - we can see it in the data. The non-fliers who don't or can't listen will end up kicking tin and settling multi-billion-dollar lawsuits for their shareholders. The story rarely varies.
It was Basil Fawlty with a small shrubbery in hand swiftly beating his little car that I had in mind... and the thread itself deserves nothing less.
FOQA ? Do Turkish operate such a scheme... sure it would have been mentioned * This would be one way of picking up continual approach busts, poor monitoring as well as that RA persistent failure.
If not, should ? now be thinking along the lines of enforcing such schemes in at least all European airlines above a certain size?
if there are 'cultural problem' airlines, would it not help get around that, the challenge coming from management or more dispassionate QA analysts with a stronger mandate (OK, I'll get shot for suggesting FO, SO hasn't the 'strongest mandate', so bullet proof vest on, but YUKWIM)
If not, should ? now be thinking along the lines of enforcing such schemes in at least all European airlines above a certain size?
if there are 'cultural problem' airlines, would it not help get around that, the challenge coming from management or more dispassionate QA analysts with a stronger mandate (OK, I'll get shot for suggesting FO, SO hasn't the 'strongest mandate', so bullet proof vest on, but YUKWIM)
The descent, since the sixties, of the curve showing the fatal accident rate, now at an all-time low, is about to start climbing again. The Turkish accident is merely the latest canary in the mine. Too many who lead in government and corporate offices are comfortably numb or paralyzed by present economic difficulties. SMS means someone in middle management must stick his/her head above the trench and call an operation because of a crew's "difficulties with the MEL...etc, etc" and that will be the end of that person's career advancement. You can't put someone who is responsible for the bottom line, in charge of safety processes and decisions.
FOQA at Turkish? At a number of safety conferences I have met and discussed FOQA programs with both western and eastern European airline safety representatives. While intentions of many are earnest, FOQA struggles to survive because of bean-counter ignorance and short-term thinking/planning. I spoke with no one from Turkey but given the public statements in Hurriyet ostensibly expressing denial of what really happened to their aircraft I would not be the least surprised if no FOQA Program existed at THY but I don't know. I'm sure someone will correct me if THY has a FOQA Program, (in which case I have some questions for them).
The corporate ignorance (and increasingly, government ignorance as governments get out of the safety business and hand it over to private corporations), of how the industry has achieved the excellent safety record it enjoys today, is increasing, partly due to lost history/experience, but mainly due to the new politics of safety. Such collective ignorance is tacitly granting permission to airline managements to set aside flight data programs which inconveniently show that not everything is well. This isn't just an opinion or reading about others' experience in trying to breath life into data programs.
One last thing...if we need a bullet-proof vest for raising notions such as the focus and first priority of FO, then my point is made. In my experience this is half the reason why SMS, an excellent concept, will fail in reality; no leadership, reduced to nil regulatory oversight - the FAA/Southwest/American/United events are cases in point.
These days, robust safety programs and processes take too much of the bottom line. Perhaps airline managements have set aside "corporate ethics", (an oxymoron if there ever was one), and are under the illusion that it is cheaper to buy the insurance? Regardless, for those who understand aviation and the fundamentals that keep it safe, the dynamics are clear. Fatal loss of control accidents are matching CFIT accidents - we can see it in the data. The non-fliers who don't or can't listen will end up kicking tin and settling multi-billion-dollar lawsuits for their shareholders. The story rarely varies.
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Yes, I know precisely what you mean and have written about here dozens of times - Flight Operations is not concerned with flight safety. It is concerned with making money.
The comparison of BEA Staines with THY AMS should be '..there but for the Grace of God go I'
It makes one wonder if a sufficiently strong suggestion that all souls could have easily been lost here might trigger a few synapses into making some links with absent FOQA programmes and meaningful CRM adoption... and the cost of a repetition.
N.B. The similarities in fact go further, with HSA being asked to detent the Trident's l.e.device/flap levers whilst Boeing may well be asked to modify the RA fit one way or another... bu there was no doubt the Staines accident was all about not flying the aircraft properly
Last edited by HarryMann; 11th Mar 2009 at 21:30.
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@study
........fly a raw data approach out of 20'000 ft from time to time.
Are you realy sure about that? I see no big challange in flying from 20K to the FAF with zero power. If it means intermittendly level offs, means lots of traffic I would consider this rather irresponsible. Besides you put a lot of stress on to your fellow pilot with no real benefits to gain.
In my last company we had 4 Sims every year, so if one wanted to sharpen ones handling skills, there we had plenty of opportunities.
Although I would agree in flying manual approaches given the right parameters (airport, weather, traffic etc) to do so.
........fly a raw data approach out of 20'000 ft from time to time.
Are you realy sure about that? I see no big challange in flying from 20K to the FAF with zero power. If it means intermittendly level offs, means lots of traffic I would consider this rather irresponsible. Besides you put a lot of stress on to your fellow pilot with no real benefits to gain.
In my last company we had 4 Sims every year, so if one wanted to sharpen ones handling skills, there we had plenty of opportunities.
Although I would agree in flying manual approaches given the right parameters (airport, weather, traffic etc) to do so.
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As a current NG driver, I am astonished how so many "experts" have already managed to solve this mystery with so little information.
Until more official information is released no one can say what was going on in that flight deck, and attempting to do so is just disrespectful.
There is a lot more to this.
Until more official information is released no one can say what was going on in that flight deck, and attempting to do so is just disrespectful.
There is a lot more to this.
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flyin heavy
if it is too much workload for the NFP so the FP can hand fly from the flight levels to a landing, then perhaps the NFP should put down his newspaper and wake up.
I am really ashamed at some of the things I am reading here. Imagine, hand flying a plane when you could press a button instead. That's like actually having a romantic encounter with a beautiful female flight attendant and letting something electrically powered do YOUR JOB>
shaking my head...where have all the pilots gone?
if it is too much workload for the NFP so the FP can hand fly from the flight levels to a landing, then perhaps the NFP should put down his newspaper and wake up.
I am really ashamed at some of the things I am reading here. Imagine, hand flying a plane when you could press a button instead. That's like actually having a romantic encounter with a beautiful female flight attendant and letting something electrically powered do YOUR JOB>
shaking my head...where have all the pilots gone?
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In my last company we had 4 Sims every year, so if one wanted to sharpen ones handling skills, there we had plenty of opportunities.
Could it be things are already worse than I thought?
Last edited by MU3001A; 12th Mar 2009 at 01:46.
pth;
The answer is blowin' in the wind, pth.
For the practically-minded, it can also be found in the history of this industry from about 1978 or so...does the date sound familiar?
shaking my head...where have all the pilots gone?
For the practically-minded, it can also be found in the history of this industry from about 1978 or so...does the date sound familiar?
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In a time were inexperienced pilots start instructing others how to fly airplanes, then buy type ratings and go sell their arts to the commercial aviation industry, the "swiss cheese holes" line up very quickly.
In this particular accident, the radio altimeter was a contributing factor, but the cause of the crash was what??
However, let us wait for the investigation results before we condemn.
In this particular accident, the radio altimeter was a contributing factor, but the cause of the crash was what??
However, let us wait for the investigation results before we condemn.
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Originally Posted by airbusa330
Faulty altimeter, thust levers commanded to RETARD and subsequent stall seems to be the consensus.
I agree with wizofoz. Automatic systems are not entirely reliable. And being myself a pilot who hasn't flown the big buses yet, it creeps the hell out of me and makes me feel umcomfortable how dependent is one system of another.
At the end, connecting this thing with that, and that other one with this other one, opens the window of possibilities where if one fails, the other fails. It gets to a point where it doesn't matter if an indicator instrument is a primary instrument or a secondary instrument, or if it is needed to be scanned or not. Because in the end, the failure of any of these sub-systems can create any kind of trouble.
And yes, we hop into a new plane and we are thrilled by knowing how it can activate retard mode by RA indication. Ok that is cool, but what if the RA fails? What is the backup for this system if it fails and what is the backup for the other systems if this same system fails?
This crash could have also been prevented if the crew were in control of the airspeed. I mean, read that last sentence again and realize how pilots are not in control or are aware of the airspeed their aircraft is flying at.
Is there a concept called "Technology-Induced Pilot Error"? Because it seems to happen a lot.
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The corporate ignorance (and increasingly, government ignorance as governments get out of the safety business and hand it over to private corporations), of how the industry has achieved the excellent safety record it enjoys today, is increasing, partly due to lost history/experience, but mainly due to the new politics of safety. Such collective ignorance is tacitly granting permission to airline managements to set aside flight data programs which inconveniently show that not everything is well. This isn't just an opinion or reading about others' experience in trying to breath life into data programs.
Excellent post PJ2, thanks.
This trend is indeed very scarry. Management forcing crews to take short cuts to improve profits. Flight Safety Managers have a position but no power whatsoever. Some Managers these days are not even pilots anymore.
They'll only learn when it's to late.
