Emergency landing Air Maroc on EHAM june 6th
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Two Weeks Ago at AMS,
Taxied from Hotel stands with permission to cross 36C for 36L departure. Reported a flock of 12 swans (flying perfect vic formation) at 30 feet flying south-north right up the middle of 36C. Tried for 3 mins to talk ATCs eyes onto them with no success. Seemed to me a lack of concern to what I considered a major hazard.
Taxied from Hotel stands with permission to cross 36C for 36L departure. Reported a flock of 12 swans (flying perfect vic formation) at 30 feet flying south-north right up the middle of 36C. Tried for 3 mins to talk ATCs eyes onto them with no success. Seemed to me a lack of concern to what I considered a major hazard.
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I think the Hudson landing illustrates how serious the problem of large birds is. If you are unlucky enough to get a large bird in both engines after take off, you'll end up in the Dutch polder or worse!
We are being warned through "notams" of the bird risk. However, there is not much we can do with a warning like that. We are not going to cancel a flight because of the risk, and once you see them it will be almost impossible to avoid.
It is a serious problem and it needs to be addressed.
We are being warned through "notams" of the bird risk. However, there is not much we can do with a warning like that. We are not going to cancel a flight because of the risk, and once you see them it will be almost impossible to avoid.
It is a serious problem and it needs to be addressed.
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Passion Flying Hobby Science Sponsor Work
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Bird strike
Perhaps a consequence of the "anti" hunting laws that prohibited hunting in Holland up to the point that Geese overpopulation now creates all sorts of problems.
m2c, d3
m2c, d3
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The preliminary report does state more than the obvious imho :
This leads me to the following observations:
1. The altitude of the aircraft being 630 feet is twice the altitude reported by ground observers but far below the required 1700 feet MSA.
2. I attended a presentation of the Robin system detecting bird migration some eight years ago at an aviation conference in the US. I am glad to see it has received fresh attention.
3. The aircraft was vectored, meaning that the low altitude route over the city of Haarlem was on the initiative of the controller and not the pilot.
4. The Bijlmer accident in 1992 where an El Al Cargo 747 crashed into an appartment block in the eastern suburbs of Amsterdam gave rise to a parliamentary recommendation to introduce city contours on the radar screens, in order to avoid reoccurrence of the Bijlmer tragedy.
5. I am looking forward to the full investigation report of this incident.
NARRATIVE
The aircraft had multiple bird strikes with geese during take-off from runway 18L. This resulted in heavy damage and loss of the left engine. The crew declared an emergency and the aircraft was vectored to runway 18R immediately. The aircraft’s climb performance was degraded. The highest altitude during the flight was approximately 630 feet. The aircraft made an overweight landing and the tires of the right main landing gear were blown.
The aircraft had multiple bird strikes with geese during take-off from runway 18L. This resulted in heavy damage and loss of the left engine. The crew declared an emergency and the aircraft was vectored to runway 18R immediately. The aircraft’s climb performance was degraded. The highest altitude during the flight was approximately 630 feet. The aircraft made an overweight landing and the tires of the right main landing gear were blown.
1. The altitude of the aircraft being 630 feet is twice the altitude reported by ground observers but far below the required 1700 feet MSA.
2. I attended a presentation of the Robin system detecting bird migration some eight years ago at an aviation conference in the US. I am glad to see it has received fresh attention.
3. The aircraft was vectored, meaning that the low altitude route over the city of Haarlem was on the initiative of the controller and not the pilot.
4. The Bijlmer accident in 1992 where an El Al Cargo 747 crashed into an appartment block in the eastern suburbs of Amsterdam gave rise to a parliamentary recommendation to introduce city contours on the radar screens, in order to avoid reoccurrence of the Bijlmer tragedy.
5. I am looking forward to the full investigation report of this incident.
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Final Report
Here is the final report (in Dutch):
Noodlanding na vogelaanvaring, Amsterdam Schiphol Airport, 6 juni 2010 - De Onderzoeksraad voor veiligheid
English version will be published later this year.
In a nutshell:
A goose caused the left engine failure during the takeoff on rwy 18L. The pilots did not follow the standard operating procedure following the engine failure at high speed (above V1). The Capt. made a right turn at 280 ft at a bank angle of 37.5 degr. Normal procedure is to continue straight ahead. Also no turns should be made below 400 ft. The crew also lowered the gear again. The crew thought that both engines had failed and anticipated an emergency landing. However, the right engine was working just fine. The aircraft was heavily vibrating which made it difficult to read the instruments. The aircraft climbed and descended several times as the crew lowered and increased the thrust on the right engine. GPWS gave warnings several times. The left engine was still running at low rpm and was shut down some 5 min. after the engine failure. The crew did not use any emergency check list. Flaps remained at the same (incorrect) takeoff setting. ATC tried to get the aircraft to 18R. The aircraft flew at low altitude with constructions and buildings around it at the same altitude. The report states that the crew took unnecessary risks with their decision not to follow SOPs. N-1 Climb performance was degraded because of the lowering of the thrust on the right engine, use of flaps and lowering of the gear.
The report also discusses the problem of geese at Schiphol in length. It also mentions crew task saturation, poor CRM and training as factors.
Read the full report to get every detail that I didn’t cover here.
Noodlanding na vogelaanvaring, Amsterdam Schiphol Airport, 6 juni 2010 - De Onderzoeksraad voor veiligheid
English version will be published later this year.
In a nutshell:
A goose caused the left engine failure during the takeoff on rwy 18L. The pilots did not follow the standard operating procedure following the engine failure at high speed (above V1). The Capt. made a right turn at 280 ft at a bank angle of 37.5 degr. Normal procedure is to continue straight ahead. Also no turns should be made below 400 ft. The crew also lowered the gear again. The crew thought that both engines had failed and anticipated an emergency landing. However, the right engine was working just fine. The aircraft was heavily vibrating which made it difficult to read the instruments. The aircraft climbed and descended several times as the crew lowered and increased the thrust on the right engine. GPWS gave warnings several times. The left engine was still running at low rpm and was shut down some 5 min. after the engine failure. The crew did not use any emergency check list. Flaps remained at the same (incorrect) takeoff setting. ATC tried to get the aircraft to 18R. The aircraft flew at low altitude with constructions and buildings around it at the same altitude. The report states that the crew took unnecessary risks with their decision not to follow SOPs. N-1 Climb performance was degraded because of the lowering of the thrust on the right engine, use of flaps and lowering of the gear.
The report also discusses the problem of geese at Schiphol in length. It also mentions crew task saturation, poor CRM and training as factors.
Read the full report to get every detail that I didn’t cover here.
Last edited by decurion; 29th Nov 2011 at 18:54.
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DSB Final Report
Accident: Royal Air Maroc B734 at Amsterdam on Jun 6th 2010, flock of birds, engine fire
The Dutch Onderzoeksraad (Dutch Safety Board DSB) released their final report in Dutch (the English version estimated to be released in the first week of December 2011) concluding the probable causes of the accident were:
1. Shortly after takeoff a collision with a bird caused damage to the left hand engine which reduced the available thrust from that engine by about 45%. The crew decided correctly to return to Amsterdam's Schiphol Airport.
2. The implementation of the return however were not in line with standard operating procedures, the deviations were:
- the execution of a right hand turn at 260 feet AGL with a bank angle of 37.5 degrees instead of continuing straight until minimum safe altitude has been reached and the gear has been retracted
- after the gear had retracted it was extended again at very low altitude
- the undamaged right hand engine was reduced from 94% to 83% N1 instead of utilising its maximum thrust available
These deviations from standard operating procedures meant the aircraft was not able to climb to minimum safe altitude, the crew had difficulty controlling the aircraft and was distracted by a number of audio and visual warnings that resulted from unfinished cockpit procedures.
3. Communication and interaction between the two pilots was not according to international standards established for airline pilots. The immediate right turn led to a marginal remaining flight performance, more difficult tasks and complications, so that both pilots did not execute their duties like handling procedures and checklists in the prescribed manner. This introduced new complications like unnecessary warnings and unstable flight.
4. Training of Royal Air Maroc and Atlas Blue did not prepare flight crew for multiple failures in flight.
- Prior to any refresher training the crew was told which failures were to expect. While this is not unusual, the training could not cater for surprise effects.
- Dealing with multiple faults was included only in the initial training for captains.
- Although the flight crew training manual as well as flight crew operations manual contained procedures and checklists to appropriately address the faults, that occurred during this flight, the managers at Royal Air Maroc and Atlas Blue considered this occurrence a unique event that can not be trained for.
5. There was insufficient account of aircraft in distress below minimum vector altitude taken in studies of necessary actions following the recommendations of the Parliamentary Inquiry Commission investigating the Bijlmer plane crash (editorial note: the crash of El Al's Boeing 747-200 4X-AXG into an apartment block at Bijlmermeer on Oct 4th 1992). Those aircraft will be in the local control zone of Schiphol, the controllers however are without information of high obstacles in the control zone creating an unnecessarily increased risk of collision. This is especially true if flown outside visual meteorologic conditions.
- Research of Dutch Traffic Control following the recommendations of the Parliamentary Inquiry Commission into the Bijlmer crash led to a framework of policies to guide aircraft in distress while flying above the town. The policies establish that the aircraft commander is responsible for flight while air traffic control is responsible to grant all available assistance to the commander, while air traffic control should keep the aircraft as much as possible within the established departure and arrival routes into the runways to limit overflying built up areas. Although the Directorate General for Aviation and Marimite Affairs agreed with these policies, the radar screens of air traffic controller do not depict built up areas.
- Around Schiphol Airport high buildings are virtually everywhere in populated areas. It is therefore not feasable to maneouver in those areas avoiding the obstacles considering the speed and turn radii of aircraft. The aircraft reached a maximum altitude of 730 feet well below the minimum vectoring altitude of 1200 feet. Only two obstacles were depicted on the controller's radar screen, however, there is a high number of obstacles in the control zone that pose a risk to aircraft flying below minimum vectoring altitude, which is especially true if flown outside visual meteorological conditions.
6. The presence of one or more birds with a large mass in the flight trajectory of an aircraft pose a safety risk, especially true for geese because of their high mass and because of them flying in flocks. Most bird strikes occur during takeoff and landing.
7. Research has shown that the responsible parties to control wild life at Schiphol Airport have exhausted their options. Besides frequently closing runways it is necessary to further reduce the risk of bird strikes in the area of responsibilities of other parties.
8. All relevant aviation, agricultural, bird and nature parties recognize the risk of bird strikes and the need to reduce that risk. Despite the concensus on these necessities there is no concensus on the impact of those necessities resulting in different views on the (cost) effective implementation of these measures.
9. The urgency of a flight can not wait for the outcomes of studies of control measures that short term reduce populations of geese as most effective methode to reduce the risk of bird strikes and long term result in a habitat management, detection of birds and deterrence capabilities in view of structural reduction of bird strike risks.
10. Several Non-Government Organisations have joined in the "Geese-7" initiative to reduce and stabilize the populations of various types of geese at a certain size. The implementation of these recommendations is pending awaiting decision by the Ministry of Economy, Agriculture and Innovation.
11. The Ministry of Economy, Agriculture and Innovation, also responsible for flight safety, has not exercised adequate control of bird strike risks.
The Royal Air Maroc Boeing 737-400 CN-RMF with 156 passengers, 4 Royal Air Maroc cabin crew and 2 Atlas Blue pilots, the captain (36, ATPL, 7,540 hours total, 7,200 hours on type) being pilot flying and the first officer (28, ATPL, 2,730 hours total, 2,308 hours on type) being pilot monitoring, departed Schiphol Airport's runway 18L, flaps were set at 5 degrees, engines stabilized at 93.8 and 94.0% N1. The aircraft accelerated through 171 KIAS during rotation (nose up attitude of 6 degrees) and became airborne, at 16 feet AGL the gear was selected up at a speed of 175 KIAS. At that moment the aircraft collided with a flock of geese, which resulted in an immediate loss of all thrust from the left hand engine, the nose landing gear indicated unsafe because of the position of the nose gear did not agree with the selected position. 6 seconds later the aircraft climbed through 140 feet at engine thrust of 45.5% N1 and 93.8% N1, the left engine remained at 45% N1 for the next 4 minutes until shut down. The first officer called out engine #1 was damaged, the call was not responded to by the captain however. The captain remarked that the aircraft was shaking violently and was difficult to control. By himself, without sharing his thoughts with the first officer, he wondered whether both engines had been damaged so that insufficient thrust remained available to sustain flight, therefore he wanted to return immediately considering the decision to return was obvious. He instructed the first officer to select the landing gear down again and declare Mayday, the first officer selected the landing gear down without discussion, then declared emergency.
At a height of 280 feet the commander initiated a right hand turn. Despite the gear being selected down the nose gear continued to indicate unsafe. By the time the first officer completed the Mayday call the aircraft had already reached a bank angle of 21 degrees, the controller recognizing the right turn instructed the aircraft to roll out at 330 degrees and expect vectors for runway 18R. The aircraft reached a maximum bank angle of 37.5 degrees (according to flight data recorder) at an airspeed that reduced from 179 to 156 KIAS. The right hand engine's thrust lever was manually reduced to 83% N1 despite autothrottle being engaged, autothrottle was subsequently disengaged. The aircraft continued to climb slowly reaching 498 feet AGL before descending again at low rate, the GPWS sounded "Don't sink! Don't sink!", the airspeed continued to decrease through 145 KIAS. 60 seconds after initiating the turn the aircraft finally rolled wings level at a heading of 344 degrees.
The captain then requested the first officer to repeat the instructions received from air traffic control and noticed that the nose gear indicated unsafe, the discussion however got interrupted by the purser who called the cockpit reporting the left hand engine was on fire. The captain ignored that message and instead instructed the first officer to tell the cabin crew they were returning to Schiphol. During the next 23 seconds the air traffic controller inquired with the first officer whether the aircraft was able to maintain altitude and whether they could accept vectors, the captain talked to the purser who repeated the left engine was on fire, the GPWS activated a number of times prompting the right thrust lever to be pushed forward until the engine reached 101% N1 and the aircraft began to climb again. After the first officer had finished the transmissions with ATC the captain requested the information to be repeated. The aircraft reached 352 feet and began to descend again, the GPWS again activated "Don't sink!" and "Too Low, Terrain!".
The purser entered the cockpit, the first officer asked him to verify through the peep hole whether the nose gear was extended, then responded to a radio transmission by ATC, which transferred the aircraft onto a discrete frequency (a frequency with no other aircraft on). The purser confirmed the nose gear was down and locked.
The captain increased the right hand thrust lever further to just below firewall, the aircraft began to climb again, the GPWS alerts ceased but nose landing gear warnings now sounded. While the two pilots discussed the new warning ATC issued a heading of 350 degrees to join the downwind for runway 18R and asked whether the aircraft was able to climb, which the crew replied in the negative to.
The gear warning ceased when the aircraft overflew the villages of Vijfhuizen and Haarlem at heights of 380 to 500 feet. When the aircraft was north of these villages ATC issued a new heading of 100 degrees and advised they were 4 miles from touchdown. The captain initiated the turn but rolled out at 065 degrees, the left hand engine was shut down following the memory checklist "Engine Fire or severe damage or separation", while the memory checklist was executed ATC issued heading 160, the instruction was not responded to and was not followed. ATC issued a heading of 210 degrees, the instruction was again not followed, only a minor right turn followed. By that time the crew had completed the memory checklist and found the aircraft north of the aerodrome passing through the extended centerline of runway 18L. ATC issued a heading of 270 to return the aircraft to runway 18R, the crew completed the rest of the checklists concerning the left engine and completed programming of the flight management computer, the aircraft turned through 110 degrees, the first officer inquired with ATC for vectors and was again instructed to turn onto a heading of 270. The crew inquired whether a landing on runway 18L was possible, the approach controller declined because of obstacle clearance (Sony Building) just north of runway 18L. The crew discussed the aircraft was difficult to control, although the engine thrust was constant the airspeed was fluctuating between 160 and 170 knots, the first officer called speed when the airspeed decrased to 156 KIAS. The captain attempted to adjust the right hand thrust lever but noticed it was already at maximum thrust and instructed to firewall the engine for 5 seconds (103.9% N1).
The crew, seeing runway 18C, inquired whether a landing on 18C was possible, which was approved, however, the crew reconsidered and decided to go ahead with the original plan to land on runway 18R, the aircraft was heading at 310 degrees. ATC issued a heading to 215 degrees, the first officer called the instruction out aloud and assisted the captain performing the turn with verbal callouts. The captain captured the localizer manually and flew the ILS with flaps still at 5 degrees. On final approach the captain instructed the first officer to advise cabin crew to not evacuate but prepare for a hard landing. The first officer did not pass that message because the aircraft was already on short final and the first officer called out speeds and sinkrates in order to assist the captain. After main wheel touch down at 175 KIAS the first officer announced the automatic wheel brakes did not engage, the captain instructed to turn the system off, the first officer suggested to keep those nose up as long as possible, followed by a safe touchdown of the nose gear. While the aircraft rolled out the captain again instructed that no evacuation would be done unless there was fire. The aircraft came to a stop on the runway, the right hand engine was shut down.
Emergency services reported no smoke or fire. The right main gear tyres deflated. The passenger disembarked via mobile stairs.
The remains of 24 geese were found in the left main landing gear, the nose landing gear and the electronic compartment.
Examination of the aircraft revealed:
- dents in the underside of the fuselage near the nose of the aircraft
- a dent in the leading edge of the vertical fin
- dents and cracks at the leading edge of the left hand engine's inlet and dents inside the engine
- three fanblades fractured at about midspan damaging all the rest of the fan blades
- the left engine's low and high pressure compressor, the combustion chamber, high pressure turbine guide vanes, high pressure turbine blades, low pressure turbine outlet guide vanes, and first to fourth low pressure turbine stages were all damaged
- on the left side of the left hand engine was soot and oil
- on the fuselage were traces of oil
- the right main gear brakes were jammed
Pollution with engine oil was reported from the village of Harleem, the investigation however could not establish the source of the oil spill stating that the aircraft did not overfly the specific area in question.
Immediately after departure of the Boeing Schiphol operations were advised of a possible bird strike on runway 18L and recovered the remains of 7 dead Canada Geese, weights between 3 and 5 kg (6.6 to 11 lbs) from runway 18L around about the extended centerline of runway 06/24.
The Dutch Onderzoeksraad (Dutch Safety Board DSB) released their final report in Dutch (the English version estimated to be released in the first week of December 2011) concluding the probable causes of the accident were:
1. Shortly after takeoff a collision with a bird caused damage to the left hand engine which reduced the available thrust from that engine by about 45%. The crew decided correctly to return to Amsterdam's Schiphol Airport.
2. The implementation of the return however were not in line with standard operating procedures, the deviations were:
- the execution of a right hand turn at 260 feet AGL with a bank angle of 37.5 degrees instead of continuing straight until minimum safe altitude has been reached and the gear has been retracted
- after the gear had retracted it was extended again at very low altitude
- the undamaged right hand engine was reduced from 94% to 83% N1 instead of utilising its maximum thrust available
These deviations from standard operating procedures meant the aircraft was not able to climb to minimum safe altitude, the crew had difficulty controlling the aircraft and was distracted by a number of audio and visual warnings that resulted from unfinished cockpit procedures.
3. Communication and interaction between the two pilots was not according to international standards established for airline pilots. The immediate right turn led to a marginal remaining flight performance, more difficult tasks and complications, so that both pilots did not execute their duties like handling procedures and checklists in the prescribed manner. This introduced new complications like unnecessary warnings and unstable flight.
4. Training of Royal Air Maroc and Atlas Blue did not prepare flight crew for multiple failures in flight.
- Prior to any refresher training the crew was told which failures were to expect. While this is not unusual, the training could not cater for surprise effects.
- Dealing with multiple faults was included only in the initial training for captains.
- Although the flight crew training manual as well as flight crew operations manual contained procedures and checklists to appropriately address the faults, that occurred during this flight, the managers at Royal Air Maroc and Atlas Blue considered this occurrence a unique event that can not be trained for.
5. There was insufficient account of aircraft in distress below minimum vector altitude taken in studies of necessary actions following the recommendations of the Parliamentary Inquiry Commission investigating the Bijlmer plane crash (editorial note: the crash of El Al's Boeing 747-200 4X-AXG into an apartment block at Bijlmermeer on Oct 4th 1992). Those aircraft will be in the local control zone of Schiphol, the controllers however are without information of high obstacles in the control zone creating an unnecessarily increased risk of collision. This is especially true if flown outside visual meteorologic conditions.
- Research of Dutch Traffic Control following the recommendations of the Parliamentary Inquiry Commission into the Bijlmer crash led to a framework of policies to guide aircraft in distress while flying above the town. The policies establish that the aircraft commander is responsible for flight while air traffic control is responsible to grant all available assistance to the commander, while air traffic control should keep the aircraft as much as possible within the established departure and arrival routes into the runways to limit overflying built up areas. Although the Directorate General for Aviation and Marimite Affairs agreed with these policies, the radar screens of air traffic controller do not depict built up areas.
- Around Schiphol Airport high buildings are virtually everywhere in populated areas. It is therefore not feasable to maneouver in those areas avoiding the obstacles considering the speed and turn radii of aircraft. The aircraft reached a maximum altitude of 730 feet well below the minimum vectoring altitude of 1200 feet. Only two obstacles were depicted on the controller's radar screen, however, there is a high number of obstacles in the control zone that pose a risk to aircraft flying below minimum vectoring altitude, which is especially true if flown outside visual meteorological conditions.
6. The presence of one or more birds with a large mass in the flight trajectory of an aircraft pose a safety risk, especially true for geese because of their high mass and because of them flying in flocks. Most bird strikes occur during takeoff and landing.
7. Research has shown that the responsible parties to control wild life at Schiphol Airport have exhausted their options. Besides frequently closing runways it is necessary to further reduce the risk of bird strikes in the area of responsibilities of other parties.
8. All relevant aviation, agricultural, bird and nature parties recognize the risk of bird strikes and the need to reduce that risk. Despite the concensus on these necessities there is no concensus on the impact of those necessities resulting in different views on the (cost) effective implementation of these measures.
9. The urgency of a flight can not wait for the outcomes of studies of control measures that short term reduce populations of geese as most effective methode to reduce the risk of bird strikes and long term result in a habitat management, detection of birds and deterrence capabilities in view of structural reduction of bird strike risks.
10. Several Non-Government Organisations have joined in the "Geese-7" initiative to reduce and stabilize the populations of various types of geese at a certain size. The implementation of these recommendations is pending awaiting decision by the Ministry of Economy, Agriculture and Innovation.
11. The Ministry of Economy, Agriculture and Innovation, also responsible for flight safety, has not exercised adequate control of bird strike risks.
The Royal Air Maroc Boeing 737-400 CN-RMF with 156 passengers, 4 Royal Air Maroc cabin crew and 2 Atlas Blue pilots, the captain (36, ATPL, 7,540 hours total, 7,200 hours on type) being pilot flying and the first officer (28, ATPL, 2,730 hours total, 2,308 hours on type) being pilot monitoring, departed Schiphol Airport's runway 18L, flaps were set at 5 degrees, engines stabilized at 93.8 and 94.0% N1. The aircraft accelerated through 171 KIAS during rotation (nose up attitude of 6 degrees) and became airborne, at 16 feet AGL the gear was selected up at a speed of 175 KIAS. At that moment the aircraft collided with a flock of geese, which resulted in an immediate loss of all thrust from the left hand engine, the nose landing gear indicated unsafe because of the position of the nose gear did not agree with the selected position. 6 seconds later the aircraft climbed through 140 feet at engine thrust of 45.5% N1 and 93.8% N1, the left engine remained at 45% N1 for the next 4 minutes until shut down. The first officer called out engine #1 was damaged, the call was not responded to by the captain however. The captain remarked that the aircraft was shaking violently and was difficult to control. By himself, without sharing his thoughts with the first officer, he wondered whether both engines had been damaged so that insufficient thrust remained available to sustain flight, therefore he wanted to return immediately considering the decision to return was obvious. He instructed the first officer to select the landing gear down again and declare Mayday, the first officer selected the landing gear down without discussion, then declared emergency.
At a height of 280 feet the commander initiated a right hand turn. Despite the gear being selected down the nose gear continued to indicate unsafe. By the time the first officer completed the Mayday call the aircraft had already reached a bank angle of 21 degrees, the controller recognizing the right turn instructed the aircraft to roll out at 330 degrees and expect vectors for runway 18R. The aircraft reached a maximum bank angle of 37.5 degrees (according to flight data recorder) at an airspeed that reduced from 179 to 156 KIAS. The right hand engine's thrust lever was manually reduced to 83% N1 despite autothrottle being engaged, autothrottle was subsequently disengaged. The aircraft continued to climb slowly reaching 498 feet AGL before descending again at low rate, the GPWS sounded "Don't sink! Don't sink!", the airspeed continued to decrease through 145 KIAS. 60 seconds after initiating the turn the aircraft finally rolled wings level at a heading of 344 degrees.
The captain then requested the first officer to repeat the instructions received from air traffic control and noticed that the nose gear indicated unsafe, the discussion however got interrupted by the purser who called the cockpit reporting the left hand engine was on fire. The captain ignored that message and instead instructed the first officer to tell the cabin crew they were returning to Schiphol. During the next 23 seconds the air traffic controller inquired with the first officer whether the aircraft was able to maintain altitude and whether they could accept vectors, the captain talked to the purser who repeated the left engine was on fire, the GPWS activated a number of times prompting the right thrust lever to be pushed forward until the engine reached 101% N1 and the aircraft began to climb again. After the first officer had finished the transmissions with ATC the captain requested the information to be repeated. The aircraft reached 352 feet and began to descend again, the GPWS again activated "Don't sink!" and "Too Low, Terrain!".
The purser entered the cockpit, the first officer asked him to verify through the peep hole whether the nose gear was extended, then responded to a radio transmission by ATC, which transferred the aircraft onto a discrete frequency (a frequency with no other aircraft on). The purser confirmed the nose gear was down and locked.
The captain increased the right hand thrust lever further to just below firewall, the aircraft began to climb again, the GPWS alerts ceased but nose landing gear warnings now sounded. While the two pilots discussed the new warning ATC issued a heading of 350 degrees to join the downwind for runway 18R and asked whether the aircraft was able to climb, which the crew replied in the negative to.
The gear warning ceased when the aircraft overflew the villages of Vijfhuizen and Haarlem at heights of 380 to 500 feet. When the aircraft was north of these villages ATC issued a new heading of 100 degrees and advised they were 4 miles from touchdown. The captain initiated the turn but rolled out at 065 degrees, the left hand engine was shut down following the memory checklist "Engine Fire or severe damage or separation", while the memory checklist was executed ATC issued heading 160, the instruction was not responded to and was not followed. ATC issued a heading of 210 degrees, the instruction was again not followed, only a minor right turn followed. By that time the crew had completed the memory checklist and found the aircraft north of the aerodrome passing through the extended centerline of runway 18L. ATC issued a heading of 270 to return the aircraft to runway 18R, the crew completed the rest of the checklists concerning the left engine and completed programming of the flight management computer, the aircraft turned through 110 degrees, the first officer inquired with ATC for vectors and was again instructed to turn onto a heading of 270. The crew inquired whether a landing on runway 18L was possible, the approach controller declined because of obstacle clearance (Sony Building) just north of runway 18L. The crew discussed the aircraft was difficult to control, although the engine thrust was constant the airspeed was fluctuating between 160 and 170 knots, the first officer called speed when the airspeed decrased to 156 KIAS. The captain attempted to adjust the right hand thrust lever but noticed it was already at maximum thrust and instructed to firewall the engine for 5 seconds (103.9% N1).
The crew, seeing runway 18C, inquired whether a landing on 18C was possible, which was approved, however, the crew reconsidered and decided to go ahead with the original plan to land on runway 18R, the aircraft was heading at 310 degrees. ATC issued a heading to 215 degrees, the first officer called the instruction out aloud and assisted the captain performing the turn with verbal callouts. The captain captured the localizer manually and flew the ILS with flaps still at 5 degrees. On final approach the captain instructed the first officer to advise cabin crew to not evacuate but prepare for a hard landing. The first officer did not pass that message because the aircraft was already on short final and the first officer called out speeds and sinkrates in order to assist the captain. After main wheel touch down at 175 KIAS the first officer announced the automatic wheel brakes did not engage, the captain instructed to turn the system off, the first officer suggested to keep those nose up as long as possible, followed by a safe touchdown of the nose gear. While the aircraft rolled out the captain again instructed that no evacuation would be done unless there was fire. The aircraft came to a stop on the runway, the right hand engine was shut down.
Emergency services reported no smoke or fire. The right main gear tyres deflated. The passenger disembarked via mobile stairs.
The remains of 24 geese were found in the left main landing gear, the nose landing gear and the electronic compartment.
Examination of the aircraft revealed:
- dents in the underside of the fuselage near the nose of the aircraft
- a dent in the leading edge of the vertical fin
- dents and cracks at the leading edge of the left hand engine's inlet and dents inside the engine
- three fanblades fractured at about midspan damaging all the rest of the fan blades
- the left engine's low and high pressure compressor, the combustion chamber, high pressure turbine guide vanes, high pressure turbine blades, low pressure turbine outlet guide vanes, and first to fourth low pressure turbine stages were all damaged
- on the left side of the left hand engine was soot and oil
- on the fuselage were traces of oil
- the right main gear brakes were jammed
Pollution with engine oil was reported from the village of Harleem, the investigation however could not establish the source of the oil spill stating that the aircraft did not overfly the specific area in question.
Immediately after departure of the Boeing Schiphol operations were advised of a possible bird strike on runway 18L and recovered the remains of 7 dead Canada Geese, weights between 3 and 5 kg (6.6 to 11 lbs) from runway 18L around about the extended centerline of runway 06/24.
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The story from Eagleflier above is also available at Accident: Royal Air Maroc B734 at Amsterdam on Jun 6th 2010, flock of birds, engine fire
The Aviation Herald version comes with pictures though.
The Aviation Herald version comes with pictures though.
The story from Eagleflier above is also available at Accident: Royal Air Maroc B734 at Amsterdam on Jun 6th 2010, flock of birds, engine fire
The Aviation Herald version comes with pictures though.
The Aviation Herald version comes with pictures though.
Eagleflier, if you already copy paste the whole story from AVHERALD, please at least have the curtesy to declare it such and put the link yourself, before somone else finds you out and does it for you. It's not your work and you don't deserve credit for it.
Rearding the report itself, the airmanship described in this report is sufficiently appalling that I do hope this gentleman is kept out of a cockpit for the future, or if not, at least out of European airspace.
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After reading the report I have some questions about the effectivity of the training of the pilots
I think that the DSB failed to make this point to RAM... although the reactions from RAM seem to indicate that they realize the issue.
The question "Why did CRM break down?" remains however. The pilots should have had CRM training before their stint at RAM. Why weren't basic CRM principles applied in the cockpit?
- The pilots were of Spanish nationality, hired via temp agencies,
- Official RAM course material was in French,
- Some non-official materials in English were available,
- Neither French nor English was the native tongue for the pilots.
- The pilots knew what situations to expect during their simulator check rides.
I think that the DSB failed to make this point to RAM... although the reactions from RAM seem to indicate that they realize the issue.
The question "Why did CRM break down?" remains however. The pilots should have had CRM training before their stint at RAM. Why weren't basic CRM principles applied in the cockpit?
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It is not clear to me if RAM is completely responsible for the captain’s poor skills and CRM. He had over 7000 hrs on the 737 and only started to work recently for RAM. You would expect that he had already sufficient skills in flying a B737 including basic CRM. The report doesn’t mention his flying history in detail. I wonder for which operators he had flown the B737 before joining RAM (or actually Atlas Blue). His statements to the DSB were also somewhat strange and in conflict with the data on the CVR (strangely enough the report doesn’t provide the CVR!). He also mentioned that the aircraft was uncontrollable and he therefore did not change the flap setting. The FDR shows that the aircraft was flying as expected with a failed engine. There were no control problems. There was only vibration due to the failed engine that was still running. The aircraft reacted to power and roll inputs. Unfortunately a lot of attention in the report is given to the geese problem. Which is important, however it has nothing to do what the captain did after the engine failure. I believe he would have done the same if the engine had failed due to another reason.
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An2 driver
Dude,
I did not copy and paste from avherald. The title says DSB final report and is available from the DSB website in dutch as well as a other sources in English.
At no time did I try to claim credit for the report.
Get a grip and don't jump at the opportunity to bash.
I did not copy and paste from avherald. The title says DSB final report and is available from the DSB website in dutch as well as a other sources in English.
At no time did I try to claim credit for the report.
Get a grip and don't jump at the opportunity to bash.
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7200hrs on type - really??? Bloody embarrassing performance to be honest with potentially grave consequences. It doesn't bare thinking about what could have happened if this had occurred elsewhere.
A complete and utter breakdown of S.A - turning below 300' with the gear re-extended on the command of the PIC!!
Bank angle over 37.5 degrees with the good engine producing less than MCT. No confirmation of the failure - The captain thought to himself that there had been loss of thrust to both engines. No query as part of a crew with regards to his opinion or reasoning behind his decision to put the gear down! No teamwork, little to no task management. It all culminated by what appeared to be a flap 5 single engine landing. Completely rushed, completely non standard! Lucky that 18C is 3300m long then!
So 7200 hours on a 737! Makes me wonder. I would be interested to see his training records.
A complete and utter breakdown of S.A - turning below 300' with the gear re-extended on the command of the PIC!!
Bank angle over 37.5 degrees with the good engine producing less than MCT. No confirmation of the failure - The captain thought to himself that there had been loss of thrust to both engines. No query as part of a crew with regards to his opinion or reasoning behind his decision to put the gear down! No teamwork, little to no task management. It all culminated by what appeared to be a flap 5 single engine landing. Completely rushed, completely non standard! Lucky that 18C is 3300m long then!So 7200 hours on a 737! Makes me wonder. I would be interested to see his training records.
Mistrust in Management
Totally agree with Kallsign Kilo
A litany of shame to be honest.
We all wonder how we would perform on that day when it it all went wrong - but I just hope I would hang on to numerous years of simulator checks where you were required to follow SOP's.
I also would be interested to see the Captain's training record. How do these people land a job in the LH seat?
Regards
Exeng
We all wonder how we would perform on that day when it it all went wrong - but I just hope I would hang on to numerous years of simulator checks where you were required to follow SOP's.
I also would be interested to see the Captain's training record. How do these people land a job in the LH seat?
Regards
Exeng
Did the report provide a transcript of the CVR?
I agree about a balanced concern both from the geese problem and the crew actions. I don't measure this as much by discussion in the report as I do by the recommendations flowing from the report.
A mention was made of high vibration. It sure would have been with that many blades missing and still running at 45% I would look to the CVR and debrief of the crew to tell me what capability they had to determine the usefulness of the other engine. They may have felt that they had a dual failure.
OK in hindsight they made some wrong choices, but it was successful, so let's go slowly about judging what would be appropriate remidial action.
I agree about a balanced concern both from the geese problem and the crew actions. I don't measure this as much by discussion in the report as I do by the recommendations flowing from the report.
A mention was made of high vibration. It sure would have been with that many blades missing and still running at 45% I would look to the CVR and debrief of the crew to tell me what capability they had to determine the usefulness of the other engine. They may have felt that they had a dual failure.
OK in hindsight they made some wrong choices, but it was successful, so let's go slowly about judging what would be appropriate remidial action.
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Did the report provide a transcript of the CVR?
1. Shortly after takeoff a collision with a bird caused damage to the left hand engine which reduced the available thrust from that engine by about 45%. The crew decided correctly to return to Amsterdam's Schiphol Airport.
The yaw would have been quite notable, regardless of the thrust decrease being instantaneous or graduated. The vibration would have been both distracting and disconcerting, however the yaw and the engine indications would have been conclusive, surely? Why concern yourself with anything else other than keeping the aircraft straight and climbing away from the ground? After all, we are talking about someone with 7200hrs of 737 time here!
Here is where it all falls apart for me
2. The implementation of the return however were not in line with standard operating procedures, the deviations were:
I would add that this is not only relative to RAM's or Atlas Blue's SOPs, but any ever published and trained in relation to a Boeing!!
- the execution of a right hand turn at 260 feet AGL with a bank angle of 37.5 degrees instead of continuing straight until minimum safe altitude has been reached and the gear has been retracted
This is just ludicrous and wouldn't correspond with anything that the crew had been trained before. The captain 'believed' but neither verbalised or sought confirmation that he was dealing with loss of thrust to both engines. So he or she acted on impulse or panic? 37.5 degrees of bank would have induced 'Bank Angle' and increased load factor reducing manouvring margin.
- after the gear had retracted it was extended again at very low altitude
This really baffles me. Why did the FO not consider this command to be contrary to the overall objective here. Why did he or she not voice their concerns about any of the actions of the captain. Inquiry and advocation? Analysis and information processing? He had called that engine number one was damaged. Why was he not left aghast by the Captain's actions? Many would have now been screaming at the guy in the fear that he was about to kill them!
- the undamaged right hand engine was reduced from 94% to 83% N1 instead of utilising its maximum thrust available
No one knows the reason why, it was probably inadvertent due to the stress of the situation.
These deviations from standard operating procedures meant the aircraft was not able to climb to minimum safe altitude, the crew had difficulty controlling the aircraft and was distracted by a number of audio and visual warnings that resulted from unfinished cockpit procedures.
The report's fairly conclusive here.
And here.....
These deviations from standard operating procedures meant the aircraft was not able to climb to minimum safe altitude, the crew had difficulty controlling the aircraft and was distracted by a number of audio and visual warnings that resulted from unfinished cockpit procedures.
- Although the flight crew training manual as well as flight crew operations manual contained procedures and checklists to appropriately address the faults, that occurred during this flight, the managers at Royal Air Maroc and Atlas Blue considered this occurrence a unique event that can not be trained for.
I don't know how they came to this conclusion. Given the increasing level of bird strikes that occur on an annual basis and the recent massive publication of Sully's encounter with the Hudson, how can the event be considered unique? It could also be easily simulated. In fact, the majority of this event is; every 6 months! All you need to do is add 'Gear Disagree' due to the damage with the nose wheel gear. The EGPWS warnings were induced by the crew due to their decision to turn at 260' and re-extend the gear. They also removed the aircraft from the protection assured when climbing straight ahead when single engine. This again is surely contrary to everything the crew were trained to do in the event of a EFATO, unless they were dealing with an engine out or emergency turn procedure.
The remainder of the incident involved:
1. The aircraft not climbing above 500' and the aircraft sinking to 352'
2. No QRH checklists completed
3. Little to no CRM techniques utilised. No decision making discussed.
4. A series of distracting EGPWS aural messages along with master caution indications and engine alerts prior to shutdown
5. Speed dropping to as low as 145KIAS whilst in the turn.
6. A manual Flap 5 landing at 175KIAS. Single Engine landings on the 737 are usually Flap 15.
So who's the Captain contracting for now then?
