Turkish airliner crashes at Schiphol

[riverside1]

Although now semi-retired I do have many thousands of hours on most versions of the 737 (in both seats) and have also been a simulator instructor on the type. Additionally I have observed a simulator session with THY and was horrified by what I saw. It reminded me very much of the unfortunate 747 freighter accident at Stansted some years ago- a relatively minor aircraft technical problem exacerbated by a complete lack of modern CRM thinking. Unfortunately THY still have a long way to go to get rid of the problematic ex-military dominance still prevalent in many airlines. Other comments can be found on Pprune from expatriate pilots echoing my experience after working for the airline.
IMHO one of the main reasons for the dramatically improved safety levels of European and US airlines has been the acceptance that ALL crew members are fallible no matter what their previous experience. It took many disastrous fatal accidents to break down the historical subservience of co-pilots and (where applicable) flight engineers.
THY along with other airlines from that part of the world still suffer from a dominance by ex-military pilots and only time will erode this problem. The current drive to employ ex-patriate pilots and instructors may (hopefully) improve matters.
In the simulator session that I observed there were no checklists available and apparently little cockpit discipline- as regards who did what and when! I was reminded by one of the crew that the PF was an ex military test-pilot.(So what?) Mobile phones were even answered during the session!
Much has been said on this and other threads about low hour pilots from approved training establishments in Europe. I consider myself fortunate to have flown with many of these people and their deeply engrained professionalism demonstrated has always impressed me. Unlike pilots of my generation who often came via a self-funded and rather chaotic route these guys have been trained in the correct way of getting the job done right from the outset. Their experience levels are, of course, low but they generally have few bad habits to get rid of and absorb new knowledge like sponges. Given the choice I would much rather share a cockpit with one of these guys (or girls) in preference to a high hour,disgruntled ,by-passed alternative!
Stall recovery is something that is routinely taught in all the Boeing approved courses and disconnection of the auto-throttle is often done (although it was not actually stipulated in the Boeing manual). There are no bans on disconnection at any time and this ensured that one was not going to have to maintain a hand on the thrust levers during the recovery manoeuvre. THY seem to be trying to claim this as an excuse for the resultant full stall of the aircraft. As other contributors have pointed out- recovery from the stick shaker on any 737NG is extremely easy because of the enormous amount of available thrust and the relatively rapid response rate of the engines (c.w the old JT8s on the 100/200 versions).
Another very common fault I have observed on simulator training is excessive trust in the A/T! (“look no hands!”) Boeing have re-iterated this recently- a hand MUST be kept on the thrust levers throughout any coupled approach. Unlike the Airbus –all Boeings have continuous feed-back to the thrust levers (even on the FBW 777 and 787) which means any significant thrust command changes can be sensed from the levers.
Schipol abbreviated approaches can be somewhat stressful at times if the crew are not familiar with them- as a result of requests to maintain speed and then join the G/S from above -but there is ALWAYS the option of a go-around. With three people in the cockpit it seems amazing that no-one reacted to the speed loss until too late. An immediate recovery from the shaker is easy but once approaching the full stall the now reduced elevator response combined with the pitch-up effect from full thrust makes things much more problematic! That is why we ALWAYS teach recovery at the stick shaker!

[xetroV]

Here's the TK1951 Human Factors Report, written by Sidney Dekker for the Dutch Safety Board. Very interesting!

[Machinbird]

The Dekker report is excellent. Looks like Boeing had better own up to being responsible for this one. This was an 'Automation Surprise'.

By the time the stick shaker activated-it was too late to save.

About the only thing that a cautious pilot could reasonably be expected to do is dirty up a bit sooner so that the final minute was not so rushed. That might have helped save the day.

[Piltdown Man]

Both Dekker's and the OVV's reports lean towards the crew not being fully aware of the actual mode of the Autothrottle yet there is no recommendation to fix this problem. Having two modes with same name is not the brightest of ideas. Given the data in the report I would have recommended a Rad Alt comparator (for all aircraft), documentation revisions to describe Autothrottle functionality during the flare and lastly renaming the RETARD mode of the Autothrottle. Rename RETARD (descent) to IDLE. Or even be really ridiculous and rename the RETARD (flare) to BANANAS. Yes, something stupid in flight!

Until we replace the Mk I human being we will continue having to train crews to operate imperfect systems in an imperfect world. Systems have to be designed that help (or warn) them when they make human errors, omissions or try to just plain cheat the system.

PM

[captplaystation]

2767 posts later it has to be said the Dekker report is comprehensive indeed, although at times I did wonder if it was sponsored by THY such is the unstinting praise for their training.

Finally, there is a world of difference between doing everything by the book, and a nation adopting the mentality required to implement this on a daily basis.

The Training Capt does not at least appear to be portrayed as an overbearing person, a pleasant surprise given what I have seen of some of his ilk in turkish companies, but I do wonder just how comfortable the other two crew would have felt calling for a go/around.

That unfortunately is more a fault of lingering cultural issues rather than the individual sat in the left seat in this particular case, and my personal experience unfortunately is that many RHS occupants in Turkish companies would let you crash the mothah rather than challenging you.
Unbelievable, and sad indeed for the 21st century, but unfortunately true.
As many suggested from day1, a slightly too smartly orchestrated AMS rushed approach with a maxed out FO and 3 guys none of whom was really minding the stove.

One could argue harsh maybe, but at the risk of being simplistic I would suggest merely succint and to the point.

[cwatters]

About the only thing that a cautious pilot could reasonably be expected to do is dirty up a bit sooner so that the final minute was not so rushed. That might have helped save the day.

Report says ...

8) There is no persuasive basis in the record to conclude that the approach was “rushed.” The crew anticipated the late glideslope capture by lowering the gear and selecting flaps 15 even before capturing the localizer, and the only items to be completed after glideslope capture were final flap setting and the landing checklist. Landing clearance had already been obtained.

[Smilin_Ed]

Quotes from the Dekker Report

Exposes design shortcomings in the Boeing 737NG AFDS/A/T systems that can lead to one part of the automation doing one thing (landing) based on
corrupted input while the other is doing something else (flying);

Isn't the crew supposed to make up for such shortcomings by monitoring what's going on. Every aircraft has shortcomings for which the crew must compensate. Otherwise, why have a crew?

Such training does not support crews in developing an appropriate mental model of how the automation actually functions and what effect subtle failures have.

Then, what does it do? Teach them to play PacMan?

[Machinbird]

Cwatters-from the Dekker report:

8) There is no persuasive basis in the record to conclude that the approach was “rushed.” The crew anticipated the late glideslope capture by lowering the gear and selecting flaps 15 even before capturing the localizer, and the only items to be completed after glideslope capture were final flap setting and the landing checklist. Landing clearance had already been obtained.

I am a great fan of Mr Dekker however.....
They were doing the landing checklist when the airspeed mousetrap was sprung. If that checklist had been done already, they would have been watching the mouseholes for problems.
The Captain was keeping the FO in the ballpark for a normal approach, but there was no reserve for the unexpected.

Smilin_Ed

Isn't the crew supposed to make up for such shortcomings by monitoring what's going on. Every aircraft has shortcomings for which the crew must compensate. Otherwise, why have a crew?

I'm not so good that I can't be caught by the right mousetrap, are you?

[NigelOnDraft]

An interesting report...

However, I disagree with the basics of attributing solely the accident to the automatics failing. Have we really got to the stage where an ATHR fault, on final app, can cause the airspeed to fatally decay, and absolve the crew?

Our (Airbus) FCOM is clear that the crew must monitor the ATHR performance, and disconnect it if it fails to maintain the selected speed.

There is no persuasive basis in the record to conclude that the approach was “rushed.”

It depends on the definition of a "rushed approach". In our company, a "rushed approach" is one where the 500' stabilised approach criteria are not met. In this case they were not - approach power was not set and the speed not correct. Depending on company SOP, had the crew checked the parameters at 1000'/500' against their requirements, the error would have been apparent.

NB in some SOPs the "NHP" is actually "PM". In this case, there was a 3rd pilot specifically to make up for a potential shortfall in "monitoring".

As ever, lessons for all to take on board. But I stand by my assertion that a failure of an AP or ATHR system does not absolve the crew

NoD

[Sciolistes]

At the beginning of the report is the following quote:

They had Flight Control Computer B (FCC B) selected as the so-called Master FCC, and had selected Autopilot B on. FCC B has its own independent radar altimeter. The training and documentation available to B737 pilots suggests that this would be sufficient for protecting the automation against left radar altimeter anomalies.

Does anybody know if the lines in the MEL that require the rad alt breaker to be collared and the A/T not to be used for approach or landing were added after the incident?

[PBL]

Originally Posted by NigelOnDraft

An interesting report...

However, I disagree with the basics of attributing solely the accident to the automatics failing. Have we really got to the stage where an ATHR fault, on final app, can cause the airspeed to fatally decay, and absolve the crew?

I might point out that Sidney's HF Report does not attribute any cause. It lists "Findings".

Only a final accident report atttributes probable cause(s). The final report on this accident did not attribute the accident "solely....to the automatics failing".

PBL

[lederhosen]

I agree with NigelOnDraft about the importance of the stabilised approach and have pointed out several times e.g. post 2572 almost exactly one year ago that this approach did not meet the usual criteria. There are plenty of other contributory factors. But as a trainer on the 737 this accident is the perfect demonstration of why being spooled up at the latest at 1000 feet in IMC is important.

[jetopa]

All it boils down to, after 139 pages, is that you are the driver, you make the difference - nobody else. Don't blame the autopilot or -throttle, the ramp guy waving into a too narrow parking spot or whatever. It's you - you get paid for monitoring what your airplane is doing. No minor component failure should bring you down, in theory.

And it's also important how you deal with human errors, because: they will happen again. Even to 'hocams'.

I once met a chief surgeon who was said to have been responsible for the death of a patient because he removed the wrong (= good) kidney instead of the right (= bad) one... He wasn't proud about it, but he never made a secret about it either and let others learn a lesson from his screw-up. I take my hat off for this way of dealing with a terrible failure.

[hetfield]

I once met a chief surgeon..

Was he turkish?

[TTail]

In my company, the MEL was revised with the non-use of associated A/P and A/T about a year after the accident, so chances are THY did not have that restriction at the time.

[BOAC]

Does anybody know if the lines in the MEL that require the rad alt breaker to be collared and the A/T not to be used for approach or landing were added after the incident?

- there before

[NigelOnDraft]

PBL

I might point out that Sidney's HF Report does not attribute any cause. It lists "Findings".

Agree - the line of my post you quote actually refers to other posts e.g.

Looks like Boeing had better own up to being responsible for this one. This was an 'Automation Surprise'.

NoD

[Sciolistes]

Thanks BOAC,

That is how I recall it but wasn't sure. In which case the report is fundementally wrong. The documentation and training available to the 737 pilots was sufficient as it clearly identified the A/T as unusable for the phase of flight. The Boeing DDG is a horrid manual that often requires careful reading, but in my opinion not in this case.

[NigelOnDraft]

Sciolistes

In your post above

The documentation and training available to the 737 pilots was sufficient as it clearly identified the A/T as unusable for the phase of flight

are you implying that:

1. If LH Rad Alt is Inop then ATHR should be disabled as per MEL (as BOAC posted)
2. Because this is in the MEL, then it should have been clear (?) / known (?) to the crew that the LH Rad Alt going offline would cause ATHR issues?

I might have missed your point, but if it is as above, I would tend to disagree, on the following lines:

1. No "knowledge" of the MEL is required IMHO. Just "how to use it" when appropriate...
2. There is no requirement to conslt the MEL after dispatch in the event of a failure... Might be good practice if there's lots of time, but clearly N/A here.
3. My experience (recently Airbus) is that some MEL requirements are not "logical", even when the remaining FCOMs are consulted... and hinting (as here) to areas someone / somewhere has decided crews do not need to know (a line has to be drawn somewhere)

NoD

[Sciolistes]

NoD,

Sorry, I wasn't aware that BOAC already raised this point earlier in the thread so I don't want to trawl over old ground again and my post was clumsy as the report clearly states:

The RA anomaly had not been reported to the crew, and there was no failure flag, no warning, no light nor any other direct annunciation about it in the cockpit.

Carry on