Turkish airliner crashes at Schiphol
Well if the conclusion of this report is that it was all Boeing's fault it's time for me to retire and never travel as a passenger in an a/c again!
Further evidence of the death of critical thinking.
Further evidence of the death of critical thinking.
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I generally do not contribute to threads any more, but I am somewhat exercised by some comments and comparison to BA038. I do have something to say about TK 1951 as well (see bottom).
First, BA038 (sorry for thread creep but I do want to be clear on this in a forum in which it has cropped up).
Professor Jim Reason gave an invited talk at the 4th IET Conference on System Safety in London in October 2009, in which he talked about what was known and not known about human factors in safety-critical systems. Many here will be aware that Prof. Reason has been a major influence on human factors thinking in aviation in the last three decades or so, indeed the ATSB (or BASI as the aviation part was known then) based their accident analyses on his classification system for many years. He described two views of operators in critical systems: "human as hazard" and "human as hero". He organised "heroic recoveries" into four categories: "training, discipline and leadership"; "sheer unadulterated professionalism", "skill and luck", and "inspired improvisation". He had six examples of "sheer unadulterated professionalism": Captain Rostrom's action for the Titanic survivors (1911); Apollo 13 (1970); the BAC 1-11 incident of 1990; BA038; and United's water landing on the Hudson River. He said that what it comes down to is "irreplaceable people": "the right person (people)"; "in the right place"; "doing the right thing"; "at the right time".
I agree with Prof. Reason, in his words, that Captain Peter Burkill, along with his colleague First Officer John Coward, is one of those humans as hero, exhibiting sheer unadulterated professionalism, one of the right people, in the right place, doing the right thing, at the right time.
Unknown to Jim at the time, I had invited Captain Burkill to participate in my keynote talk to the same conference later that day. Peter came at lunchtime just after Jim had to leave - Jim asked me to convey his regards.
I had allocated about ten minutes at the end of my talk for Captain Burkill to tell the assembled engineers what it was really like being at the pointy end of all that. The audience was fascinated (Peter is also - obviously - a compelling raconteur) and the session chair, Carl Sandom, let the time run over for about 15 minutes, because of the questions and answers from the audience, not to speak of their rapt attention.
I just wanted to make it completely clear here what people such as myself, Prof. Reason, and my colleagues working in System Safety think of the performance of Captain Burkill and First Officer Coward. We applaud it.
As far as I am concerned, S.F.L.Y. is welcome to remain in his comfortable minority of one.
Second, TK 1951, the topic of this thread.
I am familiar with the human factors investigation and what the conclusions are. The HF investigation was led and the report written by a friend and colleague, who besides having a world-wide reputation and being in my judgement one of the top five aviation human factors analysts is also a practicing 737NG pilot. So concerning TK 1951 he knows whereof he speaks.
It is a fine piece of analytical work, subtle and eye-opening (at least for me) and I recommend that everyone read the report when it comes out. The analysis does not actually fit any specific one of the views aired here (including my original view). There is something to learn for everyone (as there was for me).
I might point out, as many already have, that concepts such as "responsibility" and "blame", the things that people here are suggesting that journalists wrote about the forthcoming TK 1951 report, are not used in ICAO-standard accident analysis and reporting and I sincerely hope that they never will be. It is hard enough to get the causal stuff straight without mixing in the legal as well. Most lawyers I know are equally happy to keep them separate; it makes their tasks easier also.
PBL
First, BA038 (sorry for thread creep but I do want to be clear on this in a forum in which it has cropped up).
Professor Jim Reason gave an invited talk at the 4th IET Conference on System Safety in London in October 2009, in which he talked about what was known and not known about human factors in safety-critical systems. Many here will be aware that Prof. Reason has been a major influence on human factors thinking in aviation in the last three decades or so, indeed the ATSB (or BASI as the aviation part was known then) based their accident analyses on his classification system for many years. He described two views of operators in critical systems: "human as hazard" and "human as hero". He organised "heroic recoveries" into four categories: "training, discipline and leadership"; "sheer unadulterated professionalism", "skill and luck", and "inspired improvisation". He had six examples of "sheer unadulterated professionalism": Captain Rostrom's action for the Titanic survivors (1911); Apollo 13 (1970); the BAC 1-11 incident of 1990; BA038; and United's water landing on the Hudson River. He said that what it comes down to is "irreplaceable people": "the right person (people)"; "in the right place"; "doing the right thing"; "at the right time".
I agree with Prof. Reason, in his words, that Captain Peter Burkill, along with his colleague First Officer John Coward, is one of those humans as hero, exhibiting sheer unadulterated professionalism, one of the right people, in the right place, doing the right thing, at the right time.
Unknown to Jim at the time, I had invited Captain Burkill to participate in my keynote talk to the same conference later that day. Peter came at lunchtime just after Jim had to leave - Jim asked me to convey his regards.
I had allocated about ten minutes at the end of my talk for Captain Burkill to tell the assembled engineers what it was really like being at the pointy end of all that. The audience was fascinated (Peter is also - obviously - a compelling raconteur) and the session chair, Carl Sandom, let the time run over for about 15 minutes, because of the questions and answers from the audience, not to speak of their rapt attention.
I just wanted to make it completely clear here what people such as myself, Prof. Reason, and my colleagues working in System Safety think of the performance of Captain Burkill and First Officer Coward. We applaud it.
As far as I am concerned, S.F.L.Y. is welcome to remain in his comfortable minority of one.
Second, TK 1951, the topic of this thread.
I am familiar with the human factors investigation and what the conclusions are. The HF investigation was led and the report written by a friend and colleague, who besides having a world-wide reputation and being in my judgement one of the top five aviation human factors analysts is also a practicing 737NG pilot. So concerning TK 1951 he knows whereof he speaks.
It is a fine piece of analytical work, subtle and eye-opening (at least for me) and I recommend that everyone read the report when it comes out. The analysis does not actually fit any specific one of the views aired here (including my original view). There is something to learn for everyone (as there was for me).
I might point out, as many already have, that concepts such as "responsibility" and "blame", the things that people here are suggesting that journalists wrote about the forthcoming TK 1951 report, are not used in ICAO-standard accident analysis and reporting and I sincerely hope that they never will be. It is hard enough to get the causal stuff straight without mixing in the legal as well. Most lawyers I know are equally happy to keep them separate; it makes their tasks easier also.
PBL
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Sorry about what you read as sarcasm there, PJ2. It is just that, as you are no doubt aware, a student pilot should be taught about a lot more than just keeping the airspeed above a certain critical value so that one really cannot say that "Airspeed is Everything," and leave it at that.
Seriously, you could tell some unfortunate that and have him thinking he's in good shape in his little Cessna with 90 knots on the ASI but -1500 fpm on the VSI. If he survived that one his come-back would be, "But you told me that Airspeed is Everything!" when you would then have to try to over-ride the Rule of Primacy, when whatever you had told him first would be very firmly believed. Good luck with that!
I have had people getting their knickers in a twist when I have got all the way down to Vref on an approach, when they want to see Vref +10 or whatever they have been told is the minimum safe value carried all the way to the 50-foot point. There, in my opinion, they are placing far too much emphasis on speed alone, ignoring many other things of equal import, plus forgetting that Vref already has a 30% speed margin above stall built into it, 30% that you will have to get rid of before the airplane stops flying, usually in ground effect.
Speed awareness seems to have played an obvious role in this accident, given that we have been told the accident crew got to 80 knots there. I really do look forward to learning how this happened, when whatever the cause is given as must be taken as "plausible" even if it's also "improbable, incredible, unbelievable" or whatever else we loosely call something very, very surprising.
Who would ever have guessed that an FO would raise the flaps unbidden as the response to a stall, yet that is exactly what happened in that Colgan Buffalo accident. It is, yes, very "implausible" that any pilot would do that so that we have to try and figure out "Why?" if that is possible.
As pilots there's always a defense mechanism that comes into play when there is an accident. We want to dismiss the accident crew as exceptional, as if to say that whatever happened to them will not happen to us. "They weren't watching what they were doing!" when we, of course, always do. Yeah, except when we don't, and if there are a few other factors in play then we too might have an accident. So I think we have to wait for the report to read it carefully, put ourselves in the shoes of the dead crew and think our way through what went on there. Or we can just go into self-defensive Sky God mode, assume we could never make such an implausible mistake and carry on as we are.
One of the most Sky Godly of us all, one who was always ready to dance on the corpses of other accident pilots, made a deadly mistake of his own one day. When I heard about it (when I knew him, the airplane and the environment that killed him) I thought to myself that if he'd been a bit more open to the idea that he too could make some obvious screw-up then he and his three passengers might still be with us.
Seriously, you could tell some unfortunate that and have him thinking he's in good shape in his little Cessna with 90 knots on the ASI but -1500 fpm on the VSI. If he survived that one his come-back would be, "But you told me that Airspeed is Everything!" when you would then have to try to over-ride the Rule of Primacy, when whatever you had told him first would be very firmly believed. Good luck with that!
I have had people getting their knickers in a twist when I have got all the way down to Vref on an approach, when they want to see Vref +10 or whatever they have been told is the minimum safe value carried all the way to the 50-foot point. There, in my opinion, they are placing far too much emphasis on speed alone, ignoring many other things of equal import, plus forgetting that Vref already has a 30% speed margin above stall built into it, 30% that you will have to get rid of before the airplane stops flying, usually in ground effect.
Speed awareness seems to have played an obvious role in this accident, given that we have been told the accident crew got to 80 knots there. I really do look forward to learning how this happened, when whatever the cause is given as must be taken as "plausible" even if it's also "improbable, incredible, unbelievable" or whatever else we loosely call something very, very surprising.
Who would ever have guessed that an FO would raise the flaps unbidden as the response to a stall, yet that is exactly what happened in that Colgan Buffalo accident. It is, yes, very "implausible" that any pilot would do that so that we have to try and figure out "Why?" if that is possible.
As pilots there's always a defense mechanism that comes into play when there is an accident. We want to dismiss the accident crew as exceptional, as if to say that whatever happened to them will not happen to us. "They weren't watching what they were doing!" when we, of course, always do. Yeah, except when we don't, and if there are a few other factors in play then we too might have an accident. So I think we have to wait for the report to read it carefully, put ourselves in the shoes of the dead crew and think our way through what went on there. Or we can just go into self-defensive Sky God mode, assume we could never make such an implausible mistake and carry on as we are.
One of the most Sky Godly of us all, one who was always ready to dance on the corpses of other accident pilots, made a deadly mistake of his own one day. When I heard about it (when I knew him, the airplane and the environment that killed him) I thought to myself that if he'd been a bit more open to the idea that he too could make some obvious screw-up then he and his three passengers might still be with us.
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I just wanted to make it completely clear here what people such as myself, Prof. Reason, and my colleagues working in System Safety think of the performance of Captain Burkill and First Officer Coward. We applaud it.
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Leave BA038 out of this thread
By expat400
Just the best short answer on this thread so far! Agree 100%
By PBL
Just the best long answer on this thread, a complete delight to read sir!
BA038 has been done to death on it's correct thread do we have to here?
I will never falter on my belief that the BA 038 cockpit crew are hero's! I wish that some contributors be a little more positive towards the aviation industry instead of all the "what ifs" with out foundation in many cases flooding the threads.
Are you comparing BA 038 to this accident?
I must be reading it wrong or you are someone who has never set your feet in an aircraft...
I must be reading it wrong or you are someone who has never set your feet in an aircraft...
By PBL
I agree with Prof. Reason, in his words, that Captain Peter Burkill, along with his colleague First Officer John Coward, is one of those humans as hero, exhibiting sheer unadulterated professionalism, one of the right people, in the right place, doing the right thing, at the right time.
BA038 has been done to death on it's correct thread do we have to here?
I will never falter on my belief that the BA 038 cockpit crew are hero's! I wish that some contributors be a little more positive towards the aviation industry instead of all the "what ifs" with out foundation in many cases flooding the threads.
Per Ardua ad Astraeus
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Sorry, cessnapete, but those points are wrong!
I'd prefer not to drag out 038 here (PM if you wish), but the defect was not recorded and therefore no MEL action.
I'd prefer not to drag out 038 here (PM if you wish), but the defect was not recorded and therefore no MEL action.
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S.F.L.Y
The difference is that the BA038 crew was never trained for the "glider landing" situation, so there is no way you can demand that they should have known about best glide speeds. In contrast, the TK crew could have either just pushed the power levers or pushed the nose down for speed, before it was too late, but did neither despite they were most certainly trained for that situation. 
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... the TK crew could have either just pushed the power levers or pushed the nose down for speed, before it was too late,
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Check all my previous post if you have nothing better to do and can't elaborate on factual and technical issues.
I'm just sorry to read that in one case pilots should be considered a heroes while in the other they should be considered as zeros. This attitude is purely ridiculous and unprofessional.
To me situations were quite similar: automatic approach, lack of thrust, speed decay and no effective action to stop the AOA to increase to insane levels. In both cases aircrafts reached stick shaker without thrust. The only difference was the available height for recovery, nothing to do with heroism.
When you have no speed and no thrust you simply don't increase your attitude, that's very basic and easy to understand. 15 years old teenagers flying gliders know that they shouldn't pull on the stick if they're short on final. How does it differ in a 777?
Have the decency to stop blaming one crew while throwing roses at the other when the outcome of these accidents are only based on available height after stick shaker activation.
I'm just sorry to read that in one case pilots should be considered a heroes while in the other they should be considered as zeros. This attitude is purely ridiculous and unprofessional.
To me situations were quite similar: automatic approach, lack of thrust, speed decay and no effective action to stop the AOA to increase to insane levels. In both cases aircrafts reached stick shaker without thrust. The only difference was the available height for recovery, nothing to do with heroism.
When you have no speed and no thrust you simply don't increase your attitude, that's very basic and easy to understand. 15 years old teenagers flying gliders know that they shouldn't pull on the stick if they're short on final. How does it differ in a 777?
Have the decency to stop blaming one crew while throwing roses at the other when the outcome of these accidents are only based on available height after stick shaker activation.
Last edited by S.F.L.Y; 27th Jan 2010 at 21:05.
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Turkish airliner crashes at Schiphol
Because they were fighting to push the conrol column down. Due to gradual speed decay the pitch trim was maxed out and aircraft was trying to climb..During this struggle the throttles went back to idle.
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S.F.L.Y.
I am going to bed now, so don't expect a response in the immediate future.
Stop comparing the Turkish accident with BA038.
The difference , in case you somehow failed to notice, is that one crew were handed an impossible set of circumstances at 500ft and (according to you ) failed to optimise the glide performance of a Boeing 777, and horribly let the pilot population down by doing what 99.9% of us would do, by trying to avoid having a windscreeen full of suburbia as they tried to arrive somewhere on Thiefrow. Funny how anyone with a professional qualification and experience seems to think they did a bloody good job, where does that tend to put YOUR opinion shag ?
The "other" crew regretably, somehow, failed to notice or react to the fact that their cfm56's remained at idle thrust whilst their airspeed went West, and that in lieu of the autothrottle ,it was a good idea to react. Whilst there is sympathy for their error,and a desire to understand what may indeed have contributed to this almighty cock -up, opinion seems to be "what the hell were they looking at? " Again , where does that leave your learned "opinion " vs the experienced professional pilots posting on here?
I am sorry to say,your bitterness and constant harping on about the safety medals the pilots both so justifiably received , labels you a prize tw@t in my eyes, and your inability to see beyond this mindset combined with your posting history deprives you of any credibility.
"You are the weakest link in this thread, Good Night"
I am going to bed now, so don't expect a response in the immediate future.
Stop comparing the Turkish accident with BA038.
The difference , in case you somehow failed to notice, is that one crew were handed an impossible set of circumstances at 500ft and (according to you ) failed to optimise the glide performance of a Boeing 777, and horribly let the pilot population down by doing what 99.9% of us would do, by trying to avoid having a windscreeen full of suburbia as they tried to arrive somewhere on Thiefrow. Funny how anyone with a professional qualification and experience seems to think they did a bloody good job, where does that tend to put YOUR opinion shag ?
The "other" crew regretably, somehow, failed to notice or react to the fact that their cfm56's remained at idle thrust whilst their airspeed went West, and that in lieu of the autothrottle ,it was a good idea to react. Whilst there is sympathy for their error,and a desire to understand what may indeed have contributed to this almighty cock -up, opinion seems to be "what the hell were they looking at? " Again , where does that leave your learned "opinion " vs the experienced professional pilots posting on here?
I am sorry to say,your bitterness and constant harping on about the safety medals the pilots both so justifiably received , labels you a prize tw@t in my eyes, and your inability to see beyond this mindset combined with your posting history deprives you of any credibility.
"You are the weakest link in this thread, Good Night"
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Aerodynamic is a science, nothing to do with my personal credibility or your "experienced" aviator friends.
Increasing AOA on an engineless aircraft below Vref is severly reducing the gliding distance, that's a fact which can be confirmed by any non-qualified, non-rated, non-professional, non-credible glider pilot or C152 instructor.
Now if you like to think that in the heavy metal world rules are different and that aircrafts actually glides further at max AOA it's up to you. No need to bring the suburban jungle in the topic, ILS procedures are fortunately designed with OCH and you won't smash a building each time you slightly deviate from GS.
Increasing AOA on an engineless aircraft below Vref is severly reducing the gliding distance, that's a fact which can be confirmed by any non-qualified, non-rated, non-professional, non-credible glider pilot or C152 instructor.
Now if you like to think that in the heavy metal world rules are different and that aircrafts actually glides further at max AOA it's up to you. No need to bring the suburban jungle in the topic, ILS procedures are fortunately designed with OCH and you won't smash a building each time you slightly deviate from GS.
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Increasing AOA on an engineless aircraft below Vref is severly reducing the gliding distance
Not true, if this energy is used to get it over the fence...
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True, for a "stabilized" flight path.
Not true, if this energy is used to get it over the fence...
Not true, if this energy is used to get it over the fence...
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S.F.L.Y.
Easy to coldly apply a slice of the sciences to measure but one strand of an event when you intentionally observe through a keyhole.
Your room must be awfully tidy.
Easy to coldly apply a slice of the sciences to measure but one strand of an event when you intentionally observe through a keyhole.
Your room must be awfully tidy.
chuks;
I make the assumption here that I am writing to colleagues - to professionals who have an overall comprehension of aviation if they indicate they are licensed, and if licensed in the airline/heavy transport industry I assume experience in doing the work. I read in your bio that you had an ATPL so presumed that you would understand what is meant by the phrase I used and the way I used it.
Clearly, there is a wide variety of skills involved in flying an airplane, but it is a fundamental principle as you know, that keeping one's airspeed on the right side of the ledger is key to everything else, but that such primaries do not sacrifice everything else that one does to keep an airplane aloft and safe.
It is from that POV that I make the observation that for a professional crew to permit airspeed of an airliner to drop below Vref under any circumstances other than complete incapacitation or hijack, and down to near the 80kt range (I am led to believe), is, to put it mildly, something to examine and discover why.
I think the points you make in your response are really worth making - I have had the same experience - the 320, 330 and 340 all "sit on Vapp (Vref+5) and its a natural reaction when the airspeed is "right on bug" to wonder about the margin but your assessment is spot on. That said, at the risk of a bit of drift, I wouldn't hang on the bug in turbulent weather or with a tailwind in a 320 or 321 - its a recipe for a hard landing or a tailstrike, interestingly - it's in the data, but given your remarks I suspect you know this. Thanks for the comeback.
PJ2
It is just that, as you are no doubt aware, a student pilot should be taught about a lot more than just keeping the airspeed above a certain critical value so that one really cannot say that "Airspeed is Everything," and leave it at that.
Clearly, there is a wide variety of skills involved in flying an airplane, but it is a fundamental principle as you know, that keeping one's airspeed on the right side of the ledger is key to everything else, but that such primaries do not sacrifice everything else that one does to keep an airplane aloft and safe.
It is from that POV that I make the observation that for a professional crew to permit airspeed of an airliner to drop below Vref under any circumstances other than complete incapacitation or hijack, and down to near the 80kt range (I am led to believe), is, to put it mildly, something to examine and discover why.
I think the points you make in your response are really worth making - I have had the same experience - the 320, 330 and 340 all "sit on Vapp (Vref+5) and its a natural reaction when the airspeed is "right on bug" to wonder about the margin but your assessment is spot on. That said, at the risk of a bit of drift, I wouldn't hang on the bug in turbulent weather or with a tailwind in a 320 or 321 - its a recipe for a hard landing or a tailstrike, interestingly - it's in the data, but given your remarks I suspect you know this. Thanks for the comeback.
PJ2
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Point taken...
I think there are more amateurs (in the best sense of that word, those who love flying without necessarily being professionals) here than you might assume, just given by the tenor of the posts, so that I am uncomfortable with such a sweeping statement about speed being paramount. There's a lot of truth in that but it really needs that overview that broad experience brings, as you have pointed out.
You can see people take stuff they read (when it must be true) and embed it in their scheme of values. Often a situation develops with some misunderstanding just sprawling across the aviation landscape like kudzu that should have been uprooted to begin with.
Anytime a perfectly serviceable aircraft is destroyed with loss of life then, yes, we can almost hope that a mistake was made that we can learn from so as to avoid the same thing happening to us. I just don't like to see this distancing mechanism come into play, even though it is only natural, that "This isn't going to happen to me because I am not (insert reason or reasons here)!"
To criticise that BA crew is breath-takingly arrogant. They lost both engines on short final yet managed that to the point where everyone survived and most people even walked away yet someone can carp about how that was achieved? If this were a TV show it would have "Warning! Kids: Don't try this at home!"
You can see people take stuff they read (when it must be true) and embed it in their scheme of values. Often a situation develops with some misunderstanding just sprawling across the aviation landscape like kudzu that should have been uprooted to begin with.
Anytime a perfectly serviceable aircraft is destroyed with loss of life then, yes, we can almost hope that a mistake was made that we can learn from so as to avoid the same thing happening to us. I just don't like to see this distancing mechanism come into play, even though it is only natural, that "This isn't going to happen to me because I am not (insert reason or reasons here)!"
To criticise that BA crew is breath-takingly arrogant. They lost both engines on short final yet managed that to the point where everyone survived and most people even walked away yet someone can carp about how that was achieved? If this were a TV show it would have "Warning! Kids: Don't try this at home!"
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To criticise that BA crew is breath-takingly arrogant.
Any glider pilot perfectly knows that on high aspect ratio wings slights speed deviations from best L/D have larger effects on the gliding perfs. High deviation below Vref caused by the AP attempt to land a thousand feet beyond rwy threshold couldn't deliver best gliding distance. I'm not judging the crew as I'm only interested in knowing why performances have been limited. I'm valuating comments based on their content, not on the "prestigious" degrees held by the posters.
I don't see much difference between the two incidents (in terms of human behavior). Here is why:
1 Both aircraft were on automated approaches
2 Both crews noticed speed going below Vref and both attempted corrections with thrust adjustments
3 In both cases these thrusts adjustments were infective and speed kept decaying
4 In both cases aircrafts lost the same proportion of speed and reached stick shaker while the AP attempted to remain on the ILS.
Whatever were the causes, step 4 was reached by both crews through similar processes. At that point (4) both aircrafts can't anymore follow the ILS. At that point it's just a matter of pilot inputs and trim position...
The 777 had enough height to drop the nose and recover some energy to control the impact. In the 737 the combination of nose up trim and max thrust pitch up momentum probably limited a similar nose down recovery leading to high Vz/high AoA impact. The trim positions reached by the AP in both aircrafts could have made a big difference in the outcomes. I don't see how so called "professionals" can decide whether one crew is to be blamed and the other one to be congratulated for the few seconds following step 4 since they had similar behaviors during the preceding steps.