4th June 2010 B737-800 rejected takeoff after V1 Report is out
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SOPs are the bare minimums. In said company with so many cadets and such rapid expansion, SOPs are I dare say the only thing thoroughly instructed. Airmanship and common sense are hinted upon but the real emphasis is on SOPs. This has however rapidly created a whole group of pilots who think nothing exists outside SOPs and everything that is not covered does not exist/should not be done - see well known problem with Flemish speaking pilots. However, the aircraft itself does not know that all you know are SOPs and so does the surrounding environment (weather - passengers etc.). As expected there are some rude surprises along the way plus the perfect SOPs are so perfect they go through major annual changes. Need, not optimisation created the SOP religion in the first place until pilots get the necessary experience to know that there is more out there.
That day even SOPs were not followed. Also Company cadets are never taught they in some cases they can abort after V1 and stay in the runway - any runway, they just don't get any training on that. For an F/O to abort with the nosewheel in the air something was not right with the relationship with the Captain on the other seat. I cannot speculate more on this but maybe the combination was not optimal that day. This could be the missing link on what we do not understand.
That day even SOPs were not followed. Also Company cadets are never taught they in some cases they can abort after V1 and stay in the runway - any runway, they just don't get any training on that. For an F/O to abort with the nosewheel in the air something was not right with the relationship with the Captain on the other seat. I cannot speculate more on this but maybe the combination was not optimal that day. This could be the missing link on what we do not understand.
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SOP's as guidelines
Remember the AA DC10 at KORD? They were fine at V2+15 when their engine fell off taking out the hydraulics to the LED's. What killed everybody is the crew followed AA SOP at the time and slowed to V2. Now their SOP is if they are at V2 to V2+15 hold the higher speed, don't slow to V2.
What would you have done? Follow SOP and slow to V2 or stick with what was working at V2+15? Reading some responses here I see some who wouldn't be with us any more if they had been on that crew.
What would you have done? Follow SOP and slow to V2 or stick with what was working at V2+15? Reading some responses here I see some who wouldn't be with us any more if they had been on that crew.
I was an F/O at the time and the discussions around our crew rooms agreed that if the Capt. had let the F/O, who was doing a good job of handling the emergency, instead of taking the aircraft and flying by Company SOP's, which are a good guide, AA191's crash would have not happened.
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aterpster,
Many years ago an Old Continental 707 had an engine on the left side (I think #2, have an uncontained engine failure at LAX. They had just rotated. Debris from # 2 bounced off the runway and took out engine #3. It was hairy but they were able to climb out and return for landing.
Wasn't that a National B-727 at DCA?
Many years ago an Old Continental 707 had an engine on the left side (I think #2, have an uncontained engine failure at LAX. They had just rotated. Debris from # 2 bounced off the runway and took out engine #3. It was hairy but they were able to climb out and return for landing.
Wasn't that a National B-727 at DCA?
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We need to keep what V1 really means. It is solely based on a single engine failure. If I might quote from FAR 1
V1means the maximum speed in the takeoff at which the pilot must take the first action (e.g., apply brakes, reduce thrust, deploy speed brakes) to stop the airplane within the accelerate-stop distance. V1 also means the minimum speed in the takeoff, following a failure of the critical engine at VEF , at which the pilot can continue the takeoff and achieve the required height above the takeoff surface within the takeoff distance.
If you look at the number of RTO's, most engine failures occur relatively early in the TO roll. Late in the TO role, other problems seem to arise -- wheels, brakes, tires, and flight control problems. I'd say that V1 is only guidance for non-engine failure cases.
Several years ago, there was an RTO caused by all of the glass going dark. As it happened, it was night and the pilot rejected the takeoff. My boss at the FAA said "Never ever reject above V1." I suggested that it depends. On a clear day at KPHX, I'd go every time. On the proverbial dark and stormy night at KSEA, I'd probably take my chances and stop.
Aside from engine failures, V1 does not apply.
PS, in these late aborts, I think only the PF can make the decision.
I know I'm going to get it now.
V1means the maximum speed in the takeoff at which the pilot must take the first action (e.g., apply brakes, reduce thrust, deploy speed brakes) to stop the airplane within the accelerate-stop distance. V1 also means the minimum speed in the takeoff, following a failure of the critical engine at VEF , at which the pilot can continue the takeoff and achieve the required height above the takeoff surface within the takeoff distance.
If you look at the number of RTO's, most engine failures occur relatively early in the TO roll. Late in the TO role, other problems seem to arise -- wheels, brakes, tires, and flight control problems. I'd say that V1 is only guidance for non-engine failure cases.
Several years ago, there was an RTO caused by all of the glass going dark. As it happened, it was night and the pilot rejected the takeoff. My boss at the FAA said "Never ever reject above V1." I suggested that it depends. On a clear day at KPHX, I'd go every time. On the proverbial dark and stormy night at KSEA, I'd probably take my chances and stop.
Aside from engine failures, V1 does not apply.
PS, in these late aborts, I think only the PF can make the decision.
I know I'm going to get it now.
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It's OK if you all die but were adhering to procedure. No one can criticize you.
If you reject after V1 and survive, especially with aircraft damage, you're going to get put through the ringer. But you're alive, eh?
We brief fire, failure, fear, shear.
V1 is my guideline and I adhere, but on many occasions V1 occurs with room to stop and then some. I think about that, too.
I also strongly believe the V1 and climbout charts were based on data from new airplanes and engines flown by test pilots, and I know from experience, catastrophic engine failure at 600' after takeoff and not being able to maintain V2 in level flight, much less climb out, that older airplanes and engines will not give you charted performance, but something less. Odds are most takeoffs hit the real V1 hundreds of feet before the charts (therefore the boxes) said they did.
The best thing you can do is keep your mind spinning when the unexpected happens, go with your instinct, and fly the bastard. We can talk about the rest on the ground. When I was faced with the once in a lifetime, I kept thinking to myself, "I'm NOT going out this way!"
If you reject after V1 and survive, especially with aircraft damage, you're going to get put through the ringer. But you're alive, eh?
We brief fire, failure, fear, shear.
V1 is my guideline and I adhere, but on many occasions V1 occurs with room to stop and then some. I think about that, too.
I also strongly believe the V1 and climbout charts were based on data from new airplanes and engines flown by test pilots, and I know from experience, catastrophic engine failure at 600' after takeoff and not being able to maintain V2 in level flight, much less climb out, that older airplanes and engines will not give you charted performance, but something less. Odds are most takeoffs hit the real V1 hundreds of feet before the charts (therefore the boxes) said they did.
The best thing you can do is keep your mind spinning when the unexpected happens, go with your instinct, and fly the bastard. We can talk about the rest on the ground. When I was faced with the once in a lifetime, I kept thinking to myself, "I'm NOT going out this way!"
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I don't think a plane that can't at V1 accelerate and climb at V2 is legal to fly with an engine failure at V1. However using your judgement in dealing with near V1 failures should consider what is at the end of the runway, a cliff, or rising terrain. You don't at this point worry about legalities, you worry about survival.
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goldfish85:
Don't know about the 727 at DCA. I clearly recall the Old Continential 707 at LAX.
I can't imagine a 727 flying out of takeoff on one engine.
aterpster,
Many years ago an Old Continental 707 had an engine on the left side (I think #2, have an uncontained engine failure at LAX. They had just rotated. Debris from # 2 bounced off the runway and took out engine #3. It was hairy but they were able to climb out and return for landing.
Wasn't that a National B-727 at DCA?
Many years ago an Old Continental 707 had an engine on the left side (I think #2, have an uncontained engine failure at LAX. They had just rotated. Debris from # 2 bounced off the runway and took out engine #3. It was hairy but they were able to climb out and return for landing.
Wasn't that a National B-727 at DCA?
I can't imagine a 727 flying out of takeoff on one engine.
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bubbers44:
The OEI takeoff flight path is far more a critical operating procedure than a legality. Aborting after V1 has a terrible record. It was even worse until the industry agreed in the 1960s to reduce V1 to the minimum that performance would allow.
I don't think a plane that can't at V1 accelerate and climb at V2 is legal to fly with an engine failure at V1. However using your judgement in dealing with near V1 failures should consider what is at the end of the runway, a cliff, or rising terrain. You don't at this point worry about legalities, you worry about survival.
aterpster
{quote] Don't know about the 727 at DCA. I clearly recall the Old Continential 707 at LAX.
I can't imagine a 727 flying out of takeoff on one engine. [/quote]
Wasn't the Continental at LAX in 68 and a B720?
{quote] Don't know about the 727 at DCA. I clearly recall the Old Continential 707 at LAX.
I can't imagine a 727 flying out of takeoff on one engine. [/quote]
Wasn't the Continental at LAX in 68 and a B720?
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Aborting after V1 has a terrible record.
Most late aborts happen because something has gone very wrong which was not detectable (or sometimes not noticed) until after rotation. Nasty surprises with little or no time to make a proper analysis of the problem. In many cases the aircraft is simply unflyable and an incident is inevitable.
Reduced power takeoffs are fashionable nowadays but IMHO are daft. The runway behind you is always useless. Safety compromised to save a few bucks.
Incorrect flap settings are a recurrent cause, this should not happen, unflyable as configured.
Unexpected control responses can have many causes, recent cases include improper or no de-icing, incorrect weight&balance, overloading, and maintenance issues such as several cases of incorrect rigging of B1900 controls. Most of these are either unflyable or dangerous to fly.
Multiple engine failures are rare after v1, usually caused by bird strikes, but again the aircraft may or may not be flyable.
V1 is only appropriate to single engine failures, it is simply irrelevant in any of the above cases.
My survival guide is simple, always be prepared for the unexpected. Know your airfield, does it have a cliff, hotel or cabbage patch at the end of the runway ?. Have a plan ready, keep a running assessment of available stopping distance until safely airborne. The crash tenders are going to reach you a lot sooner in the cabbage patch than 5 miles after takeoff.
And just hope that when it happens to you you get lucky and have 4000 metres of runway left as I did.
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I have been watching this thread develop with considerable interest.
I have no criticism of the FO who was doing the best he could with the resources he had available at the time and the experience, training and system which he had been exposed to preceding the incident.
But what I do criticise is the ethos and system which has produced this result. Flying is not an academic exercise but definitions of matters such as "V1" are. Many accidents and incidents in previous aviation history have proved that high speed stops are quite risky - lots of "M" and masses of "Vsquared" gives boatloads of energy to dissipate in one form or another - whereas continued take off at speeds close to V1 are usually much safer (hey why not use that energy to go flying?!). Does that mean I think you should never stop after V1 - NO! (but I'd have to have a damn good reason to do so!).
I would like to focus on another issue though. Over recent years we have seen a progressive attempted degradation in the authority of the aircraft Commander almost to the extent that decisions on the flight deck are made by consensus. Does this mean that I think the role of the FO is inferior? Of course not - a good commander will, when time permits, listen to the comments of the FO and if necessary act upon them to ensure safe operation. But we now have words such as "Advocacy" being banded about which lead some FOs to think this gives them licence to almost run the operation. This on top of all sorts of "touch feely" buzz words/phrases and acronyms to cover almost everything except how you walk out to the aeroplane is leading many newbies to think that flying is a "book" exercise and that the old codger in the left hand seat has to be pitied because actually "I know best because I've had all this amazing training" - in short, I see lots of overconfidence based on a system which attempts to codify and simplify what, in many cases, can only be learned from years of experience. Does this mean I think we shouldn't have procedures? No BUT it's the thinking that this breeds that everything is "cut and dried" - in short, I see much overconfidence.
In this case where the SOPs (in common with most other operators) specify that the Commander (left hand seat pilot) is the sole person who will action a rejected take off, he was probably in a better position to make the correct decision anyway as he wasn't actually flying the take off so he had more spare capacity to watch what was happening. He might have seen an airspeed trend arrow near V1 misbehaving but (rightly) decided not to call same since this would be an unnecessary distraction close to V1.
In closing, I have to say I find this incident very disturbing. I repeat that I have no criticism of the FO who "believed" he was doing the right thing but the system which has allowed this to happen.
In other circumstances this could have been a serious accident with the loss of many lives. The final question I would ask is, in this case who would have been liable? The a/c commander would have, in my opinion, a good case for saying that his authority and responsibility for the flight had been taken away the instant the FO elected to reject the take off.
I have no criticism of the FO who was doing the best he could with the resources he had available at the time and the experience, training and system which he had been exposed to preceding the incident.
But what I do criticise is the ethos and system which has produced this result. Flying is not an academic exercise but definitions of matters such as "V1" are. Many accidents and incidents in previous aviation history have proved that high speed stops are quite risky - lots of "M" and masses of "Vsquared" gives boatloads of energy to dissipate in one form or another - whereas continued take off at speeds close to V1 are usually much safer (hey why not use that energy to go flying?!). Does that mean I think you should never stop after V1 - NO! (but I'd have to have a damn good reason to do so!).
I would like to focus on another issue though. Over recent years we have seen a progressive attempted degradation in the authority of the aircraft Commander almost to the extent that decisions on the flight deck are made by consensus. Does this mean that I think the role of the FO is inferior? Of course not - a good commander will, when time permits, listen to the comments of the FO and if necessary act upon them to ensure safe operation. But we now have words such as "Advocacy" being banded about which lead some FOs to think this gives them licence to almost run the operation. This on top of all sorts of "touch feely" buzz words/phrases and acronyms to cover almost everything except how you walk out to the aeroplane is leading many newbies to think that flying is a "book" exercise and that the old codger in the left hand seat has to be pitied because actually "I know best because I've had all this amazing training" - in short, I see lots of overconfidence based on a system which attempts to codify and simplify what, in many cases, can only be learned from years of experience. Does this mean I think we shouldn't have procedures? No BUT it's the thinking that this breeds that everything is "cut and dried" - in short, I see much overconfidence.
In this case where the SOPs (in common with most other operators) specify that the Commander (left hand seat pilot) is the sole person who will action a rejected take off, he was probably in a better position to make the correct decision anyway as he wasn't actually flying the take off so he had more spare capacity to watch what was happening. He might have seen an airspeed trend arrow near V1 misbehaving but (rightly) decided not to call same since this would be an unnecessary distraction close to V1.
In closing, I have to say I find this incident very disturbing. I repeat that I have no criticism of the FO who "believed" he was doing the right thing but the system which has allowed this to happen.
In other circumstances this could have been a serious accident with the loss of many lives. The final question I would ask is, in this case who would have been liable? The a/c commander would have, in my opinion, a good case for saying that his authority and responsibility for the flight had been taken away the instant the FO elected to reject the take off.
SBT, well said.
Overconfidence in part; elsewhere a disturbingly low understanding of the factors involved in safety and certification, encouraging bias and opportunity for poor judgement, both at the sharp end and blunt end of operations.
Some evidence of an “I know better” syndrome, almost to the point of reversion to the pre CRM, ‘P1’ only days.
Safety culture, national culture, professional culture?
Similar problems in a related subject, here:-
Winter Operations, Friction Measurements and Conditions for Friction Predictions - Executive Summary
Overconfidence in part; elsewhere a disturbingly low understanding of the factors involved in safety and certification, encouraging bias and opportunity for poor judgement, both at the sharp end and blunt end of operations.
Some evidence of an “I know better” syndrome, almost to the point of reversion to the pre CRM, ‘P1’ only days.
Safety culture, national culture, professional culture?
Similar problems in a related subject, here:-
Winter Operations, Friction Measurements and Conditions for Friction Predictions - Executive Summary
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Over recent years we have seen a progressive attempted degradation in the authority of the aircraft Commander almost to the extent that decisions on the flight deck are made by consensus.
The captain also interpreted the feeling as engine asymmetry. Therefore the captain performed an additional engine cross check during the takeoff roll. However, no difference in engine indications was observed. Nor was the cross-check communicated to the first officer who was flying, this was however not mandated either.
Then there is this gem:
In the operators guidance and rules it is written that the captain is the only one with the authority to reject the takeoff. For this reason the hand of the captain is near engine controls in case of a decision to reject the takeoff. In the event of a controllability issue it is very likely the pilot flying is the crewmember who experienced and is faced with the problem, in this case it was not the person authorised to make the rejected takeoff decision.
This case isn't a good example of a F/O undermining the Captain's authority. It's a good example of how an arrogant Capitan and backed up by the thoughtless SOP of a company make a mockery of the notion of a safety culture.
In closing, I have to say I find this incident very disturbing. I repeat that I have no criticism of the FO who "believed" he was doing the right thing but the system which has allowed this to happen.
In other circumstances this could have been a serious accident with the loss of many lives. The final question I would ask is, in this case who would have been liable? The a/c commander would have, in my opinion, a good case for saying that his authority and responsibility for the flight had been taken away the instant the FO elected to reject the take off.
In other circumstances this could have been a serious accident with the loss of many lives. The final question I would ask is, in this case who would have been liable? The a/c commander would have, in my opinion, a good case for saying that his authority and responsibility for the flight had been taken away the instant the FO elected to reject the take off.
So I may have missed something here in all these pages, did the FO undermine the Captains authority or just act out his decision role?
If the later we're spending way too much time second guessing decisions made in seconds, leave that to the chief pilot who has access to all the inputs
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Couldn’t agree more with SBT’s observations.
@ Mountainbear: “And that's OK with everyone because the Capt is the boss and who the hell cares what the PF is thinking? Is that really what CRM is all about?"
Yes indeed, the captain is the “boss” of the aircraft (if you feel like using the word “boss”). Despite how much some individuals like to see it, the flight deck is not a democracy. Captain holds final authority and responsibility. Get over it.
In Ryanair, where the incident took place, it is captain’s decision to abandon a take off. FO´s in Ryanair are, to my knowledge, not even trained the RTO actions. This partly explains why the FO in this particular case just closed the thrust levers and left the remainder of the RTO actions for the captain. A likely scary situation for the “arrogant” captain.
A little more on CRM: CRM is about making optimum use of all available resources i.e. equipment, procedures and people with the final goal of promoting/enhancing flight safety. An excellent concept that in recent years clearly has improved flight safety and, as a side effect, created a pleasant atmosphere in the flight deck. The concept of CRM has also resulted in a culture where inexperienced FO’s learn much faster as they are more included in the general decision making process. People progress much faster if they are not limited to “just watch and copy” practices/culture. However, IMHO, too often CRM is seen by inexperienced and over SOP-ed FO´s as “my sector, my flight, my decision(s)”. That is not how CRM works.
Any sensible captain will take into account what the FO, Cabin Crew, dispatcher, ATC (and, in some cases, even passengers), … have to say (why those who advocate CRM are so often stuck in their Capt vs. FO box and forget about the valueable info that might come from ‘ the ground’ or ‘the back’?). That is what CRM is all about : maximising your recourses and then make a sensible decision. Yet, at V1 the decision to go has been made and a take off is continued.There is no room/time to have a little chat on how save/unsave is it to continue the take off near, at or after V1. In plain English: only one person is and can be in charge.
@ Mountainbear: “And that's OK with everyone because the Capt is the boss and who the hell cares what the PF is thinking? Is that really what CRM is all about?"
Yes indeed, the captain is the “boss” of the aircraft (if you feel like using the word “boss”). Despite how much some individuals like to see it, the flight deck is not a democracy. Captain holds final authority and responsibility. Get over it.
In Ryanair, where the incident took place, it is captain’s decision to abandon a take off. FO´s in Ryanair are, to my knowledge, not even trained the RTO actions. This partly explains why the FO in this particular case just closed the thrust levers and left the remainder of the RTO actions for the captain. A likely scary situation for the “arrogant” captain.
A little more on CRM: CRM is about making optimum use of all available resources i.e. equipment, procedures and people with the final goal of promoting/enhancing flight safety. An excellent concept that in recent years clearly has improved flight safety and, as a side effect, created a pleasant atmosphere in the flight deck. The concept of CRM has also resulted in a culture where inexperienced FO’s learn much faster as they are more included in the general decision making process. People progress much faster if they are not limited to “just watch and copy” practices/culture. However, IMHO, too often CRM is seen by inexperienced and over SOP-ed FO´s as “my sector, my flight, my decision(s)”. That is not how CRM works.
Any sensible captain will take into account what the FO, Cabin Crew, dispatcher, ATC (and, in some cases, even passengers), … have to say (why those who advocate CRM are so often stuck in their Capt vs. FO box and forget about the valueable info that might come from ‘ the ground’ or ‘the back’?). That is what CRM is all about : maximising your recourses and then make a sensible decision. Yet, at V1 the decision to go has been made and a take off is continued.There is no room/time to have a little chat on how save/unsave is it to continue the take off near, at or after V1. In plain English: only one person is and can be in charge.
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I think SBT has hit the nail on the head - there will always be a tension between SOPs and common sense. Attempts to "codify" expertise are not just found in the airline industry - Jeffery Pfeffer authored "The Human Equation" which contains a chapter entitled "Why Smart Organisations Sometimes Do Dumb Things".
He notes that the problem occurs in demanding accountability for a decision or judgement "process" rather than the outcome of that decision. When forced to account for and explain decisionmaking in ways legitimate and comprehensible to a wider audience (e.g. PPRUNE or the regulator) the expert will have to forego any insight or intuition that can't be articulated and will be forced to rely, instead, on the same data and decision process as anyone else. In doing so the expert loses virtually all the benefits of their expertise.
It seems those responsible for the SOPs necessary for operational consistency and regulatory compliance must also recognise and ensure that they protect wisdom, knowledge and competency in their organisations. A tricky but valuable balancing act.
RL
He notes that the problem occurs in demanding accountability for a decision or judgement "process" rather than the outcome of that decision. When forced to account for and explain decisionmaking in ways legitimate and comprehensible to a wider audience (e.g. PPRUNE or the regulator) the expert will have to forego any insight or intuition that can't be articulated and will be forced to rely, instead, on the same data and decision process as anyone else. In doing so the expert loses virtually all the benefits of their expertise.
It seems those responsible for the SOPs necessary for operational consistency and regulatory compliance must also recognise and ensure that they protect wisdom, knowledge and competency in their organisations. A tricky but valuable balancing act.
RL
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@ Amos2: CRM: use the available recources. One of your pax could be a another pilot or engineer. A recent incident in a South European country springs to mind where one of the pax told cabin crew during taxi that they just hit another aircraft with their wingtip. Turns out the pax was an engineer. Turns out he was right. Turns out the crew was not aware.
I wouldn`t go as far as making a PA though in every abnormal or emergency. Most likely the info from “the great unwashed down the back” will come to you without a PA. Some of it might be valueable.
I wouldn`t go as far as making a PA though in every abnormal or emergency. Most likely the info from “the great unwashed down the back” will come to you without a PA. Some of it might be valueable.