BA 747 Crew commended

[p51guy]

The Air Florida crash was caused because the engine anti ice was not turned on and the epr probes gave eroneous readings. If they had just advanced the power beyond the max epr they would not have crashed. The epr reading was wrong because engine anti ice was turned off. Florida guys are not that familiar with icing conditions. I for one. They made a terrible mistake that morning. I felt it in my gut when they crashed because I was flying a 737 also in California and knew something went wrong. The heroes that jumped in to save the passengers are still in my mind. I agree with pushing the thrust levers to the limit when things go south. Years ago during Air Florida times they didn't have thrust limiters but they do now. The computer would have probably not given them the power they needed today either if the engine anti ice was turned off.

[protectthehornet]

dozzywannabe:

Anyone who has flown 737's or anything with underwing mounted engines notices the first flight that if you add power the nose goes up...conversely reducing power makes the nose go down.

A basic concept of holding pitch would be...throttles forward, yoke forward, throttle back, yoke back.

The pitch up you mentioned was also caused by the way the leading edge devices were set back in those days...the british had even noticed that in icing conditions with flaps less than 15degrees, the pitch up could be bad.

The first officer/copilot did notice something wrong and called it out...the young pilot, who didn't know jack, could have looked at N1 which should have been in the high 90's%. There seems to have been a lack of checklist discipline, whether by poor design or misunderstanding. Firewalling the engines and pushing forward on the Yoke might have saved them...but they didn't try.

I made mention of a TV movie depicting the events, and even with dramatic license, the point should be well made.

AS to the modern engines, protected with computers and dippers and limiters, it is too bad. But, as Iunderstand it, a reduced power takeoff has procedures associated with it. One of them demands full power if an engine fails (two engine plane), of course the 747 is a 4 engine plane and if a simple engine failure had happened little required.

However, any time you are not performing as expected on takeoff, one might want to check the flap position (including leading edge) and throttles forward...and if that ain't working, what the hell, push the throttles to the stop.

I haven't flown the 747 which I mentioned earlier, but I have flown enough planes to know that if the power is right and the performance isn't right...you have a few seconds to figure things out.

I suggest to boeing, that some sort of takeoff over ride switch be fitted to command the slats/leading edge devices to remain extended on takeoff. Pilot presses button prior to takeoff...hey plane, I'm going to takeoff so don't retract the slats no matter what!!!

[p51guy]

I don't think adding one more thing to the takeoff checklist is good. It happened once so just be aware of it. Stick shaker on take off is an automatic reduction of pitch to stop it. Staying close to or on the runway while accelerating is good so you don't pull it up into a stall. We normally rotate with over 6,000 ft of runway in front of us so why should we be concerned with climb at this point. Just fly. Don't stall.

[fjordviking]

In Joburg with a fully loaded 747 you don`t have more than 6000 ft of runway
left when you rotate.

[Mike Whiskey Romeo]

ETOPS,

Thanks for clarifying that

Mike

[DozyWannabe]

Err... PTH, I don't think I was part of the Palm 90 tangent! Though I'd say that incident was probably one of the most fascinating examples of poor CRM (at a company level as well as in the flight deck) I know of. Also, I think p51guy is right. Having an "override" in effect actually increases system complexity in an engineering sense as well as in terms of the checklists.

[Checkboard]

But, as Iunderstand it, a reduced power takeoff has procedures associated with it. One of them demands full power if an engine fails (two engine plane)

No - the reduced thrust calculations ensure that the engines are providing all of the required thrust for that take off - including enough for single engine performance. There is no requirement to increase thrust after an engine failure in a reduced thrust take off.

I suggest to boeing, that some sort of takeoff over ride switch be fitted to command the slats/leading edge devices to remain extended on takeoff. Pilot presses button prior to takeoff...hey plane, I'm going to takeoff so don't retract the slats no matter what!!!

The pilot already presses a switch for take off - the "TOGA" switch - to set power.

[protectthehornet]

dozzywannabe...so sorry...intended for air rabbit...pilot error.

for reduced power takeoffs, we had the option of powering up to full power if an engine failure happened...but certainly adequate power for the segments of engine out climb existed.

good point about the toga switch...simply wire it into the equation to make sure the slats don't retract in critical situations.

[AirRabbit]

Part 1 of 5:

I see that there have been several responses to my post regarding the tragic Air Florida accident in Washington, DC in January of 1982. In order to do any justice at all to those who were kind enough to offer comments, and the length such responses would require, I have elected to split my response into 5 parts; and I will try to load those 5 parts as close to one another as the system will allow.

I cannot fault many of the conclusions voiced on this thread, because much of what has been posted is an understanding taken directly from the National Transportation Safety Board (NTSB) official accident report. The point is that this report is flawed. Sorry … but that is a true statement. The NTSB doesn’t often make the mistakes that are present in this report – and I’m not at all impugning the very fine reputation of the many fine men and women that work at the NTSB. But, that does not change the fact that some of the conclusions reached in this report do not “square” with other information contained in the same report. In some cases conclusions were reached with no substantiation of facts … in other cases conclusions were reached in direct opposition to known facts to the contrary. As is true in most accident reviews, we have learned a lot about a lot of things. Were the accident scenario presented to a flight crew today, knowing what we know today, and how we’ve changed our training and training requirements today, there is an excellent probability that the accident would not occur today. But 28 years ago is not today. We did not know then, what we know now. Again, my responses here are not designed to be accusatory or sarcastic … but I am passionate about this business and sometimes (shoot, probably most of the time) that passion is easily misunderstood to be an “in-your-face” response. If any of my responses sound that way, let me apologize in advance – that is not my intent.

Originally Posted by Airbubba

Well, they only had about 1.70 actual EPR set instead of 2.04, there was plenty of power left in those JT8D's. Remember, you can MEL the EPR gauges and go with N1 for power setting on this engine. As the NTSB comments on page 81 of its report:

A couple of points: It is interesting to recognize that: “hindsight” usually provides a much better understanding than “foresight;” humans are prone to develop habit patterns; habit patterns can be an aid in accomplishing routing functions … and they can be a silent enemy, waiting to pounce.

In regards to the habit patterns … anyone who flew jet airplanes 28 years ago would immediately recognize that the primary power indicating instrument used by flight crews was the EPR gauge (and that is likely still true today). However, BECAUSE of this particular accident, it has been drilled into the heads of today’s flight crews that the remaining engine instruments must be observed – not merely to recognize that they are “symmetrically” aligned – but to recognize what those other instruments are indicating. The routine training issues 28 years ago included monitoring the engine instruments – and they primarily were looking for fluctuations on an individual gauge or obvious non-alignment with the adjacently located instrument for (the/an) other engine. Also typical was to have the EPR gauge located at the top of the “instrument stack” – i.e., from top to bottom they were usually arranged something like EPR, N1 tachometer, EGT, N2 tachometer, and Fuel Flow. The point is that the top of the stack was almost always the EPR indications. However, as many of you recognize, this was not always this way. In fact, the B-737 that crashed had an instrument stack that was arranged as follows: N1 tachometer at the top, followed by EPR, EGT, N2 tachometer, and then Fuel Flow.

Following “routine, habit generated” engine instrument checks, the flight crew on the accident airplane would likely have looked first at the EPR indication – as it was deemed to be the primary indication for that purpose, and found that it was indicating 2.04 – the computed EPR for takeoff. And then, following the habit pattern, their gaze likely moved down the stack from that point, glancing at the EGT, N2, and Fuel Flow. Again, following the habit pattern, not noticing any indication being asymmetrical (i.e., one EGT indicator wasn’t at 9 o’clock and the other EGT indicator at 11 o’clock), and not having any indicator fluctuating, they likely concluded that the engine power was, indeed, “set for takeoff.”

As I said above, hindsight is valuable for accident review. The actual thrust being produced by each engine was approximately 75% of maximum – calculated by a sound spectral analysis of the engine sounds recorded on the CVR. Had the crew been trained differently and had they been admonished during that training and their subsequent operations to identify the individual values being indicated by the other engine instruments on every takeoff (as pilots do today) – they likely would have recognized that there was a problem. However, this was not the traditional training regimen at that time – not just for this airline, but for the airline industry in general. Why? Because engines were very reliable and when they malfunctioned, that malfunction was rather easily identified. The reason we do things differently today is BECAUSE of this accident.

The reason that the engines were producing only about 75% power was because the PT2 probes were blocked – likely with ice, but of course that could not be confirmed – and the flight crew set engine power in accordance with the EPR gauges. An indication of 2.04 would have resulted in the engines producing 75% power.

Here are a couple of points that will be important later in this post:
1) If the PT2 probes were blocked with ice (and I think they likely were) had nothing to do with the fact that it was snowing at the time of the accident.
2) The fact that the engines were not producing 100% thrust had nothing to do with the accident – in fact, had the crew pushed forward on the throttles, ignoring any engine indicating instrument – even at the initiation of the takeoff roll – the accident would have occurred exactly the way it occurred.
3) The airplane was certificated to accelerate to V1, lose an engine (a complete failure) and then continue the takeoff with the one remaining engine operating at takeoff power. The accident airplane had 75% of the power that should have been available under normal circumstances. Clearly, that is 50% more power than what the airplane had been certificated as requiring – and, that power was symmetrical between the two engines, not asymmetrical, where all of the available power would have been coming from only one of the two engines.
4) Airplanes fly on airspeed … not on engine power settings.

[AirRabbit]

Part 2 of 5:

Originally Posted by Checkboard

As to the Air Florida – take-off power was never set, as the P2 sensors were iced up, giving an erroneous EPR reading. The FO made several comments about the engine indications at the start of the take-off roll, if I recall correctly.

While it is true that the PT2 probes were likely blocked (see the above section of this post) there is nothing in the CVR that indicates either pilot recognized any engine anomaly or any curiosity about the engine indications. Here is a partial transcript of the CVR …
1558:55 LC “Palm ninety taxi into position and hold, be ready for an immediate”
1558:58 RDO2 “Palm ninety position and hold.”
(several entries completing Before TO checklists, Pax announcements, etc.)
1559:24 LC “Palm ninety cleared for takeoff
1559:26 RDO2 “Palm ninety cleared for takeoff”
1559:28 LC “No delay on departure if you will, traffic’s two and half out for the runway”
1559:32 CAM1 “Okay”
1559:32 RDO2 “Okay”
1559:45 CAM1 “Your throttles”
1559:48 CAM (sound of engine spool-up)
1559:51 CAM1 “It’s spooled.”
1559:55 CAM2 “Got ‘em?”
1559:57 CAM1 “Real cold.”
1559:58 CAM2 “God, look at that thing.”
1600:02 CAM2 “That don’t seem right … does it?”
1600:05 CAM2 “Ah, that’s not right.”
1600:07 CAM2 “Well…”
1600:09 CAM1 “Yes it is ... there’s eighty.”
1600:10 CAM2 “Naw, I don’t think that’s right.”
1600:11 E451 “Fourteen fifty-one cleared to land over the lights”
1600:19 CAM2 “Ah … maybe it is…”
1600:21 CAM1 “Hundred and twenty”
1600:23 CAM2 “I don’t know”
1600:31 CAM1 “Vee one.”
1600:33 CAM1 “Easy”
1600:36 LC “Six eight gulf taxi into position and hold … be ready”
1600:37 CAM1 “Vee two”
1600:38 68G “Position and hold six eight gulf”
1600:39 CAM (Sound of stickshaker starts and continues to impact)

As you can see, there was never an indication as to what it was that generated the exchange between the pilots. And, significantly, it seems as though whatever it was that was causing the F/O some consternation wasn’t clear, even to him, as he seems to be vacillating about his concern – and voiced that vacillation almost immediately. Surely it can be seen that whatever it was, certainly was not recognized by the Capt. The conclusion reached by the NTSB regarding “engine anomalies” was a post-accident decision – after reviewing what other situations could possibly have caused such comments from the F/O (“That don’t seem right … does it?”). Was it the position of the control wheel – perhaps being positioned with a slight “wing down” position when neither pilot was holding it? Was it the column position? Was it the position of the trim indicator? Was it the cabin pressure indication with the advancement of throttles for takeoff? Why was the conclusion reached that it was “engine anomalies?” What anomaly would it have been? My personal opinion, having been involved in many accident investigations and having considerable experience in training and human factors, I think it was the “muscle memory” the F/O recognized – the position of his arm was likely not where he expected it to be with the EPR indication showing takeoff power position. But, because it was something that wasn’t immediately identifiable (like an engine anomaly) he was unable to identify what it was that was making him “concerned.”

[BOAC]

Before you get too far down the 5 parts, think again about Part 1 para 3) and how you get to V1?

[AirRabbit]

Part 3 of 5:

Originally Posted by p51guy

The Air Florida crash was caused because the engine anti ice was not turned on and the epr probes gave eroneous readings. If they had just advanced the power beyond the max epr they would not have crashed. The epr reading was wrong because engine anti ice was turned off. Florida guys are not that familiar with icing conditions. I for one. They made a terrible mistake that morning. I felt it in my gut when they crashed because I was flying a 737 also in California and knew something went wrong. The heroes that jumped in to save the passengers are still in my mind. I agree with pushing the thrust levers to the limit when things go south. Years ago during Air Florida times they didn't have thrust limiters but they do now. The computer would have probably not given them the power they needed today either if the engine anti ice was turned off.

Originally Posted by punkalouver

I should think that if the Air Florida guys had not taken off with a bunch of wet snow on the wings, they would not have had their pitch-up. If they had bothered to turn the engine anti-ice on, they would have had their proper power setting for takeoff and there would not have been a need to add a bunch of thrust just to get to takeoff thrust. Somehow, I think they would have been in a better position if a normal thrust setting was used for takeoff. Doing a powerback from the gate on a heavy snow day in a 737 seems to be a strange decision as well.

A couple of comments here …
The critical mistake that was made was not made by the company or the flight crew. The critical mistake was improperly deicing/anti-icing the airplane (more later). There is no indication that the crew elected to attempt a takeoff with “a bunch of wet snow on the wings.” That certainly was the allegation made … but what was the reasoning behind that allegation?

This position was generated primarily from the interview of, and a picture taken by, a passenger on board an aircraft taxiing past the accident B-737 when it was still at the departure gate. The records of that particular flight (i.e., “block-in” time) would strongly suggest that the photo was taken just minutes prior to the accident airplane pushing back. While the black and white copy of the photo is accurate, it doesn’t do the justice to the scene content that the original color photo does; and FYI, the black and white version can be seen in the Accident Report copy. The photo clearly shows the B-737 with significant snow and ice all over the airplane. Conclusion … the flight crew departed with all that snow and ice covering the airplane.

Support for that position (if one is inclined to need it) can be “read into” some of the comments made by the flight crew on the CVR. For example, the F/O statement, “…this one’s got a quarter to half an inch on it all the way.” However, this comment simply cannot be referencing his aircraft. From the cockpit it is impossible to see the wing “all the way.” In fact, only the wing tip and about 6 feet inboard from that point would have been able to be seen from the cockpit. Recall as well, the visibility was quite poor – down to 1500 – 1800 RVR, and it was snowing. The light level was more likely equivalent to dusk than mid-day under a clear-sky. The distance from the cockpit window to the wing tip is something on the order of 65 – 70 feet. Someone would have to believe that the F/O could see ¼ inch of ice under those conditions. Additionally, the statement made by the F/O immediately following clearly shows that his comment is directed toward the airplane they are following (“Look how the ice is just hanging on his, ah, back, back there, see that?”). Besides, the purpose of the deicing/anti-icing procedure is to eliminate all snow or ice that may have been adhering to the aircraft, and the crew was likely of the understanding (now, understood to be untrue in all cases – but not then) that any falling snow would have fallen on a “protected” wing or fallen on a wing that had been cleaned, and then dried … allowing any snow to have been swept off the wing during the first portion of the acceleration – as was the understood and accepted practice at the time.

But, I digress … back to the photograph “evidence.” The photograph clearly shows a line of baggage carts parked in front of the right wing, with the forward cargo door clearly open. Testimony of the baggage loaders, those who actually conducted the deicing/anti-icing process, those that pushed the aircraft, and the gate personnel verify that no baggage was loaded on the airplane at any time after the deicing/anti-icing had been completed. It isn’t rocket science to understand that the snow and ice on the airplane seen in the photograph was not on the aircraft after the deicing/anti-icing process. Therefore, the flight did not taxi out with the snow/ice on the airplane that is indicated in the photograph. They taxied out after being deiced/anti-iced in accordance with what they thought was proper procedures.

Regarding the allegation that “Doing a powerback from the gate on a heavy snow day in a 737 seems to be a strange decision as well” … The crew did not “powerback” from the gate. Initially, after starting engines at the gate, the tug originally used was slipping on the ramp and was unable to push the airplane (more about that below…). As a result, the Capt elected to open the thrust reversers to negate the residual forward thrust on engines at idle in the hope (apparently) that the tug would then be able to successfully push the airplane. It was not successful. The engines were shut down and a much larger tug was brought in to do the push. Engines were started on the ramp after being pushed back.

Regarding the allegation that “…if the Air Florida guys had not taken off with a bunch of wet snow on the wings, they would not have had their pitch-up.” … The pitch up was, indeed, due to ice accumulation on the wings – not the wing lifting surface as much as on the leading edge of the wing … and it did not come from the snow/ice as seen in the photographic evidence (as described above) and it did not come from the falling snow during the taxi out operation. The aircraft immediately in front of the B-737 (“Apple fifty-eight”) and the aircraft immediately following the B-737 (“six eight gulf”) both took off successfully – after being exposed to the identical inclement conditions. Where did the ice come from then?

The accident airplane was deiced before push-back. However, as indicated in the NTSB report, there was an earlier malfunction in the de-icing truck and the ground crew made improper repairs. This resulted in drawing only from the water tank when the volume of the spray was anything above the “ON” position dribble out of the nozzle. When the water/glycol mix was determined at the mix station, the mixture at the hose-end was correct; but, and its worth saying again … whenever any increase in volume flow was needed (by pulling harder on the “trigger”) ALL of the increase in fluid came from the water tank – NONE came from the glycol tank. Essentially the airplane was deiced with hot water. Subsequently, when a top coating of 30% glycol would have been evenly sprayed over the entire airplane – it was sprayed with water … which promptly froze in the 22-degree weather. The crew believed they had no ice on the airplane. Not very many airplanes are deiced with water – carefully, all over the airplane, with particular attention given to the lifting surfaces, when its way below freezing outside. The fact that the deicing/anti-icing process was carried out essentially with water, it is little wonder that when a tug attempted to push the airplane back, it was slipping on the ice that had accumulated on the ramp … after the ramp was sprayed with water. Should we be surprised in that?

If you will allow me, I’d like to look at simple, straightforward aerodynamics, and what role those aerodynamics played in what happened. We know that during the initial portion of any acceleration for takeoff, the wing is beginning to develop lift. But it is not until the pilot rotates the airplane, getting the wing to an AoA that generates enough lift that the airplane gets into the air. I’m sure that it isn’t any super revelation to state that the wing does not generate lift uniformly and the entire wing doesn’t generate lift simultaneously. You and I know that you can get an airplane into the air, in ground effect, before it is really ready to fly outside of ground effect. We know that Vmu tests are done where the controls are essentially held back from early in the acceleration run, forcing the tail onto the ground (or very close to it) at a speed well below what is necessary to fly – to see what the minimum lift off speed will be. The reason pilots don’t rotate the airplane prior to reaching “rotate speed” is that they don’t want the airplane getting into the air until the wings support the airplane properly and controllably. This is what they learn. This is what they expect.

But, what would happen if we changed the equation a bit – right at that critical moment – when the pilot moves the control column to a “neutral position, or slightly aft of the neutral position, in preparation to rotate” (a quote from the Boeing manual). What if, at that moment, the pilot realized that pulling further back on the controls would not get the airplane rotated? The pilot, pulling like crazy on the controls, gets no rotation. I know that Air Force KC-135 instructors and evaluators are (or, at least were) trained on the unique use of the spoiler panels. Under the glare shield were 2 guarded switches that controlled 2 valves to open (or shut off) hydraulic pressure to either the inboard spoilers (L) or the outboard spoilers (R) on each wing. In this case (no rotation – and you had to know that the KC-135 had p*ss poor brakes and no reverse thrust – quick stops were not made with any regularity) and you wanted to get into the air, you would turn off the inboard spoilers, grab the speed brake lever, and gradually, very gradually, raise the speed brakes. With the inboard panels shut off, the only spoiler panels being raised were the outboard panels, creating differential lift – lift on the inboard portion (forward) and no lift on the outboard portion (aft). The airplane would rotate just like “normal” and when you got the pitch attitude you needed, you lowered the speed brakes, just as gradually. If you yanked the spoiler handle up quickly, you would very likely smack the tail on the ground. Differential lift at takeoff can be very interesting, to say the least.

In the accident B-737 situation, a very similar circumstance was handed to an unsuspecting crew. Recall the F/O had indicated that he intended to just get the nose gear into the air and then let the airplane "fly off the runway." Is that what happened? No, it wasn’t. When the F/O moved the control column to the neutral position, the inboard portion of the wing was generating lift – and the outboard portion was not. Presto. Rotation. Very quick rotation. All the way into the stall buffet. In approximately 2 seconds. Normal rotation rate is 3 degrees per second. Stall buffet is beyond "stick shaker," and estimates were that to get the buffet the pitch attitude would have to be approximately 24 degrees - that would require a 12-degree per second rotation rate. Does that sound like getting the nose gear into the air and then just letting the airplane fly off the runway, as the F/O indicated he was going to do? Once rotated and airborne, the crew couldn’t get rid of the differential lift. They couldn’t get the nose down. Straightforward aerodynamics. The only thing they could have done was to run the horizontal stabilizer to a more nose down position, and that may have allowed them to lower the nose; maybe. Or, they could have attempted to roll the airplane to help get the nose down. But the portion of the wing in front of the ailerons was aerodynamically crippled.

Regarding the allegation that “… there would not have been a need to add a bunch of thrust just to get to takeoff thrust. Somehow, I think they would have been in a better position if a normal thrust setting was used for takeoff” … if the airplane had been kept on the ground long enough to accelerate to a speed that would have allowed the outboard portion of the wing to generate enough lift to counter act the rotational moment, they probably would have recognized a “sluggish” airplane – with only 75% power. But they didn’t know to do that. They wouldn’t have been able to do that – even if they had shoved the throttles to the firewall at brake release. They had always planned to rotate at the computed speed. They got ready to rotate at the computed speed. They expected the airplane to fly at the computed speed. What they didn’t expect was a wing deiced with water; a wing that now had a thin coating of ice that deformed the leading edges; deformed just enough to cause this very unique aerodynamic problem – from which they were incapable of recovering.

Additionally, as I indicated earlier, the F/O had been an F-15 ADC pilot operating out of Minot, North Dakota. It probably won't surprise many that most people recognize that it does snow in Minot, North Dakota.

[AirRabbit]

Part 4 of 5:

Originally Posted by protectthehornet

Anyone who has flown 737's or anything with underwing mounted engines notices the first flight that if you add power the nose goes up...conversely reducing power makes the nose go down. A basic concept of holding pitch would be...throttles forward, yoke forward, throttle back, yoke back.

Essentially, I agree with your premise … but it is wholly dependent on the control authority retained by the elevator surface(s). If that(those) surface(s) does(do) not have sufficient authority, the airplane will not respond as you indicate regardless of what the flight crew does with the controls in the cockpit.

Originally Posted by protectthehornet

The pitch up you mentioned was also caused by the way the leading edge devices were set back in those days...the british had even noticed that in icing conditions with flaps less than 15degrees, the pitch up could be bad.

On January 13, 1982, (yes, this was the same day as the Washington, DC accident) in Scandinavia, another B737 was subjected to a rather fierce snow/freezing rain scenario while taxiing out and awaiting takeoff clearance. As the crew initiated the takeoff and brought the control column “to neutral or slightly aft of neutral to prepare for the rotation” (quote from the Boeing manual), that B737 auto-rotated just like the B737 in Washington. However, because this airplane was subjected to a crosswind, the deformation on the wings was asymmetrical. The airplane pitched up to about the same pitch attitude as in Washington (in the neighborhood of 24 degrees) but because of the asymmetrical deformation, the pitch was asymmetrical as well, and resulted in a pitch up and roll. The crew had the control column against the forward stops. They slammed the throttles to the firewall, went to full opposite aileron, full opposite rudder – all to no avail. Please note … additional thrust was not beneficial. The crew was along for the ride. However, as the roll continued over toward 90-degrees, the nose began to fall. As the nose began to come down toward the horizon (because of the bank - not because of the forward control position), the airplane began to accelerate. As it accelerated, the outboard portion of the affected wing began to produce lift and the aileron became effective. The crew rolled level less than 100 feet above the ground. When advised of the existence of this circumstance, the NTSB chose not to look into it.

Originally Posted by protectthehornet

The first officer/copilot did notice something wrong and called it out...the young pilot, who didn't know jack, could have looked at N1 which should have been in the high 90's%. There seems to have been a lack of checklist discipline, whether by poor design or misunderstanding. Firewalling the engines and pushing forward on the Yoke might have saved them...but they didn't try.

Of course there will always be the “coulda, woulda, shoulda” comments on almost anything … post-incident. The F/O did express concern over something – but, while the NTSB is convinced it was an “engine anomaly,” I am of the opinion that we don’t know what it was that garnered his interest. I gave my opinion above. But, clearly there was nothing said … and it would make sense that, if there was something that was identifiable, the F/O would have indicated what it was that was bothering him. Therefore, I maintain that is wasn’t an “engine anomaly” that was recognizable by reference to the engine indicating instruments. Additionally, he was vacillating over whatever was bothering him.

Again, from the CVR transcript:
1600:02 CAM2 “That don’t seem right … does it?”
1600:05 CAM2 “Ah, that’s not right.”
1600:07 CAM2 “Well…”

Clearly there is the following sequence: concern – possible resolution of that concern – concern – possible resolution of that concern.

Adding thrust would not have made any difference – and it did not make any difference to the crew in Scandinavia. Pushing forward on the control column had little, if any effect. If we can believe the CVR transcripts, both pilots were pushing forward on the controls. Again, from the CVR transcript:
1600:31 CAM1 “Vee one”
1600:33 CAM1 “Easy”
1600:37 CAM1 “Vee two”
1600:39 CAM (Sound of stickshaker starts and continues to impact - there is also a noticeable sound of the stall buffet).
1600:45 CAM1 “Forward, forward”
1600:47 CAM? “Easy”
1600:48 CAM1 “We only want five hundred”
1600:50 CAM1 “Come on, forward”
1600:53 CAM1 “Forward”
1600:55 CAM1 “Just barely climb”

[AirRabbit]

Part 5 of 5:

Originally Posted by protectthehornet

… any time you are not performing as expected on takeoff, one might want to check the flap position (including leading edge) and throttles forward...and if that ain't working, what the hell, push the throttles to the stop.

It’s hard to argue with this premise. Of course, that makes sense – but, I would hasten to point out that it makes sense in light of reviewing this particular accident. And, I would remind everyone, that, as it was not the engine thrust that caused or contributed to the accident, shoving the throttles forward in this particular situation, would not have changed the outcome. Again, it was heavily overcast and the light conditions were more like dusk. The visibility was between 1500 and 1800 feet. It was snowing. The runway surface was being obliterated by the collecting snow. In this particular situation, it would have been exceptionally difficult to recognize that the airplane “was not performing as expected.”

Originally Posted by DozyWannabe

Though I'd say that (this) incident was probably one of the most fascinating examples of poor CRM (at a company level as well as in the flight deck) I know of.

Again, CRM was a concept that grew out the review of this particular accident. The crew was, to the best of their understanding, managing the resources that were available to them. They relied on others to do the jobs they each were responsible for doing. They were relying on the ground crew to do their jobs. They were relying on ATC to do their jobs. They were relying on what and how they had been trained and what they were expecting.

One other point: the NSTB report indicated the Capt. elected to not use engine anti-ice during ground operations. Actually, if you look at the CVR transcript, during the “after start checklist” challenge and response – as read by the F/O and responded to by the Capt – the challenge “Engine Anti-ice” – is indicated in the CVR as “(Off).” Please note the parentheses around the word, “off.” That is NTSB-speak to indicate the clarity of the CVR was poor enough to not be sure of what the response actually was. Since there are only 2 responses to such a checklist challenge – either “On,” or “Off,” while it is true that the NTSB chose to publish the transcript with “(Off),” it would have been equally as logical and just as defensible to have published, “(On).” There are two switches in the cockpit and three valves in each engine for the functioning of engine anti-ice. When the wreckage was recovered, the condition of the cockpit overhead was such that the switch position for these particular switches was not able to be determined. Of the engine valves (6 of them), 2 were found to be motored closed, 2 were found to be motored open, and 2 were found to be broken and “free-wheeling.”

Additionally, the choice to use or not use the engine anti-ice after engine start, under the conditions that existed at the time, was completely up to the Captain – and either choice was perfectly in alignment with the operating procedures as provided by the Boeing Airplane Flight Manual. The decision to not use that system was no more correct and no more incorrect than a decision to use that system.

[AirRabbit]

Originally Posted by BOAC

Before you get too far down the 5 parts, think again about Part 1 para 3) and how you get to V1?

I am presuming that you believe I’m not considering the requirement that you accelerate to V1 with all engines operating? As you can see … I do remember. However, my point is that as long as you get to V1 it makes little difference as to how you got there, how much runway you used getting there or anything else. Once you are there, you are there – and from that point forward, the only relevant aspect is that you have takeoff thrust on the remaining engines; i.e., 1 engine on a 2-engine airplane; 2 engines on a 3-engine airplane, or 3 engines on a 4-engine airplane.

[JW411]

This is pprune at its very best for thread drift.

A BA crew gets commended for dealing with a difficult take-off problem in a 744 in JNB, South Africa which is several thousand feet above sea level and, now, within a couple of pages, we are about to be immersed in a freezing river in Washington D.C. in a 732 just off the end of DCA.

Those of you who remember anything about the Air Florida disaster and have any interest in crews being put under enormous pressure to get the job done by the management might also remember the graffiti sprayed inside one of the jetways at MIA.

As best as I can recall it said "Dick Skully before Skully Dicks You". Whatever that might have meant I simply cannot imagine.

Isn't thread drift wonderful?

By the way, well done to the BA crew.

[ExSp33db1rd]

Back to leading edge flaps ........

I don't think adding one more thing to the takeoff checklist is good. It happened once so just be aware of it.

akcherly .......... more than once.

Lufthansa 747, Flight 540, 20th Nov. 1974, Nairobi .......

from the accident report Quote .......

............ the lack of adequate warning systems which could have alerted the crew to the problem. Two previous occurrences of this error had been reported.

I freely admit that I have no experience of EICAS messaging, but the BA report suggests that an 'amber' i.e. low level, warning, appeared on the EICAS screen about the L.E. flaps, and 'may not ' have been noticed - can't comment, but the Classic 747 had a bright green / amber light above the flap angle indicators, and had that light extinguished, and turned amber as the flaps started to retract, I might suggest that it would have been more noticeable than a 'tap on the shoulder' from a computer ?

That doesn't mean that it was more likely that the crew might have abandoned take-off anymore than they did on this occasion, rightly or wrongly, but it would appear that they didn't notice the EICAS message - if I've interpreted the report correctly (?)

There has been a recent PPRuNe thread asking if we rely too much on computers - QED (?) Bells and whistles and flashing lights do tend to concentrate the mind, but maybe a definitive essay in plain language of precisely what is the problem is really the way to go ?

Perhaps a 747 -400 driver might comment ?

[By George]

Standard Boeing procedure: EICAS msg before 80 knots abort, above 80knots ...Go. This does not mean you are not allowed to think, just better be right, or you'll be nailed to a cross with blunt sticks.

[L337]

but the BA report suggests that an 'amber' i.e. low level, warning, appeared on the EICAS screen about the L.E. flaps, and 'may not ' have been noticed

There was no low level warning on the EICAS screen about the L.E. flaps. The warning was a "Dual ‘REV’ amber EICAS message."

That caused the LE flaps to retract. That retraction was not annunciated because the aeroplane thought it was doing the correct thing...

[wiggy]

but the BA report suggests that an 'amber' i.e. low level, warning, appeared on the EICAS screen about the L.E. flaps,

As I understand the report they got a amber "REV" annunctiation for one engine below V one, followed by another REV annunctiation above V one. Those are not warning messages, as in a "Caution" or "Advisory" EICAS message, they simply appear as an indication of reverser status above the appropriate engine's EPR strip gauge at the top of the EICAS screen. In addition the Flap indication would have turned magenta since the actual flap position no longer agreed with that commanded by the Flap lever - because the LE's had in part started to retract.

Edited to add: In agreement with L337's post - these are in part the normal indications you see on the -400 landing roll. With the weight on wheels switch made, and the reversers indicating unlocked the aircraft "thought" it was in the landing roll, so you wouldn't get any knobs bells or whistles about the config.....