Air Blue crash was caused by Captain
It is interesting to consider the similarities between this accident and AF447 (and others) – re “seems to me that … had completely lost any idea of where he was or what he was doing ...” (BOAC #104).
These accidents were self-made; the roots of the contributing causes occur much earlier in the event than the EGPWS warnings, or the ‘failures’ in the crew's CRM (or other meaningless terms).
In most aspects it is the lack or loss of appropriate awareness, understanding the situation, the changes, and the importance of unfolding events – triggers for change, which are the key issues.
In some respects the limitations in human performance also appear self-inflicted – mental incapacitation, inability to think; to evaluate, understand, plan, review, change, decide, and check. Perhaps the industry doesn’t get enough practice in these basic skills.
These accidents were self-made; the roots of the contributing causes occur much earlier in the event than the EGPWS warnings, or the ‘failures’ in the crew's CRM (or other meaningless terms).
In most aspects it is the lack or loss of appropriate awareness, understanding the situation, the changes, and the importance of unfolding events – triggers for change, which are the key issues.
In some respects the limitations in human performance also appear self-inflicted – mental incapacitation, inability to think; to evaluate, understand, plan, review, change, decide, and check. Perhaps the industry doesn’t get enough practice in these basic skills.
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The PBS conundrum was mentioned in the report and it said it was unauthorized.
If so, why was it in the data-base?
I don't know.
Someone sent me a paraphrase of the report today. At one point he was 15 degrees nose-up. A 25 right bank was followed by a 54 degree left-bank applied manually. Before impact he was 5 degrees nose-down.
If so, why was it in the data-base?
I don't know.
Someone sent me a paraphrase of the report today. At one point he was 15 degrees nose-up. A 25 right bank was followed by a 54 degree left-bank applied manually. Before impact he was 5 degrees nose-down.
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M. Mouse,
Sir, your comments are very astute and pertinent.
I hope my position is clear and it entitles me to be a member of this august Forum. My memories are a little faint and my knowledge needs constant up-dating. I am not so young anymore.
Sir, your comments are very astute and pertinent.
I hope my position is clear and it entitles me to be a member of this august Forum. My memories are a little faint and my knowledge needs constant up-dating. I am not so young anymore.
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The only two things we know about accidents is that there is never a single cause and also that there is always human error. To say the Captain caused the accident is incorrect. There are always other issues, not the least of which would be training.
Originally Posted by Jazz Hands
How do you take control away from a captain who's still "controlling" the aircraft, without a fight ensuing?
jjeppson @ 24th Dec 2011, 04:20 post #23
Are you sure? It isn't quite that simple, even in the US Airforce let alone a third world Muslim country. Watch the short video linked below then research the lead-up.
"No matter what seat you are in, you don't just sit there while the other pilot tries to kill you! Where were these guys trained?"
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You can always take the aircraft away from your captain but you usually will lose your job in the process. I did it once in a 4 engine corporate jet landing on a wet runway at night with a strong crosswind on a short runway.
He was way high and unstabilized and he went to landing flaps and pulled the power off approaching the threshold. I said no we are going around and pushed the throttles up and went around. I thought I was for sure fired but wanted to stay alive. When we landed he thanked me. I was surprised. He was my Chief pilot. Don't ever let a pilot in the other seat endanger your flight. Left or Right.
He was way high and unstabilized and he went to landing flaps and pulled the power off approaching the threshold. I said no we are going around and pushed the throttles up and went around. I thought I was for sure fired but wanted to stay alive. When we landed he thanked me. I was surprised. He was my Chief pilot. Don't ever let a pilot in the other seat endanger your flight. Left or Right.
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I have been thinking through this 'conundrum' of why fly so far out. It appears that the Captain 'thought' he was in NAV. There had been some attempt to programme some waypoints into the Sec FPL. Can it be that in his confused mind - in a sort of magenta line world - he 'thought' the machine was following the LNAV? Of course, any map display would clearly show divergence from the 'planned' route, but I do not think the report says what they were looking at. I can find no other explanation for length of time spent on the heading towards the hills. There had been discussion about a 5 mile downwind point, and if 'he' thought they were still going 'there', they could easily have arrived at 7 miles with the confusion over why it was not 'turning'.
I need a bit of input from the AB community here - the switching from ILS to HDG appears logical at DA and for the start of the circle. The Captain then 'thinks' he goes to NAV but stays in HDG, and at para 8:31 the report says the 'lateral mode was changed to NAV'. Can anyone suggest a clue as to what was going on? Presumably a switch to NAV when ?off? the planned LNAV route would engage wings level on existing heading?
I need a bit of input from the AB community here - the switching from ILS to HDG appears logical at DA and for the start of the circle. The Captain then 'thinks' he goes to NAV but stays in HDG, and at para 8:31 the report says the 'lateral mode was changed to NAV'. Can anyone suggest a clue as to what was going on? Presumably a switch to NAV when ?off? the planned LNAV route would engage wings level on existing heading?
To say the Captain caused the accident is incorrect.
I don't buy that nonsense
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right down to the poor captain who had no choice but to run into a hill because everyone let him down.
The buck stops with the aircraft captain.
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I would venture to say that which AP mode he was using and what he should have been using is the weakest -- and somewhat confusing -- part of the report except it notes he was using an "unauthorized" procedure.
I can only guess he stayed in NAV while he kept turning the Heading bug to the left, but did not engage it. Eventually he did, and the a/c turned right. At that point he seemed to be in state of complete panic, switching off the AP, over-banking the aircraft, pitching it up to 15 degrees at one point, followed by that unfathomable descent at the end.
I find it difficult to read the report again because it is becoming a very distressing read.
I can only guess he stayed in NAV while he kept turning the Heading bug to the left, but did not engage it. Eventually he did, and the a/c turned right. At that point he seemed to be in state of complete panic, switching off the AP, over-banking the aircraft, pitching it up to 15 degrees at one point, followed by that unfathomable descent at the end.
I find it difficult to read the report again because it is becoming a very distressing read.
BOAC: On the Bus it is usual to have at least the opposite runway inserted in the SEC FLT PLAN when a " circle to land " is anticipated.
At the breakoff point from the ILS heading will be used to establish the turn into the circuit. At that point the PNF would normally ACTIVATE the SEC FLT PLAN and only then, could NAV be engaged again.
By PBD I assume the posters are referring to Place/Bearing/Distance pilot generated waypoints and hence these would not be in any data base.
At the breakoff point from the ILS heading will be used to establish the turn into the circuit. At that point the PNF would normally ACTIVATE the SEC FLT PLAN and only then, could NAV be engaged again.
By PBD I assume the posters are referring to Place/Bearing/Distance pilot generated waypoints and hence these would not be in any data base.
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Originally Posted by maajam
The PBS conundrum was mentioned in the report and it said it was unauthorized.
If so, why was it in the data-base?
If so, why was it in the data-base?
"Unauthorised" doesn't mean the FMS will forcibly prevent you from entering such a PBD if you so wish. It means entering PBD's for that specific purpose (circle to land) and presumably that specific place was unauthorised.
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Meikle - I'm happy with that, but not sure what the NAV function on a circle to land would do for you - does it simply change runway or are you presented with an LNAV option for a visual manoeuvre?
Any comments on my last para?
Any comments on my last para?
I Have Control
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A few questions.
Was the P-B-D inserted into the primary flt plan, the secondary, or both? At what point exactly was the secondary activated?
Did the a/c have TERR ON ND function? If so, was it displayed? And if so, which ND? Was the radar on? Displayed properly? Which ND? And at what tilt?
Without knowing answers to these questions (and others, I am sure), we will never know what exactly happened, let alone why.
But from the transcript, it seems that something was stifling the FO from alerting, challenging, and ultimately taking control of the a/c. My guess is that the flight deck atmosphere was about as poisonous as that of G-ARPI, which Stanley Key presided over. And the old chestnut of abusive captain's incapacitation was raised in that accident as well.
Did the a/c have TERR ON ND function? If so, was it displayed? And if so, which ND? Was the radar on? Displayed properly? Which ND? And at what tilt?
Without knowing answers to these questions (and others, I am sure), we will never know what exactly happened, let alone why.
But from the transcript, it seems that something was stifling the FO from alerting, challenging, and ultimately taking control of the a/c. My guess is that the flight deck atmosphere was about as poisonous as that of G-ARPI, which Stanley Key presided over. And the old chestnut of abusive captain's incapacitation was raised in that accident as well.
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BOAC
Meikle - I'm happy with that, but not sure what the NAV function on a circle to land would do for you - does it simply change runway or are you presented with an LNAV option for a visual manoeuvre?
Any comments on my last para?
Preparing secondary flight plan for opposite runway before circling does nothing to navigate the maneuver, it is used only to get benefit from ground speed mini function when you use managed speed. Airbus doesn't prohibit circling without activating secondary flight plan to opposite threshold but in latter case selected speed shall be used instead of managed. Like on any normal airplane circling is described in therms of headings and timings and not by NAV via pilot created PBDs.
The situations was further aggravated as captain turn the heading knob but didn't pull it and autoflight remained in NAV. This Bus feature (pull knob to switch to selected guidance) is really confusing and it's happened to me several times just to rotate and not pull noticing this error only by FMA readout. Being under stress captain rotated heading to 086 (as stated in the report) - too much to the left to intercept final - because airplane didn't do what he expected, so he continued to rotate heading bug up to 086. Finally, when he realized mistake he pulled heading knob and that's why airplane started right turn instead of left (to the shortest direction).
That's what I can imaging reading the report (IMHO).
Meikle - I'm happy with that, but not sure what the NAV function on a circle to land would do for you - does it simply change runway or are you presented with an LNAV option for a visual manoeuvre?
Any comments on my last para?
Preparing secondary flight plan for opposite runway before circling does nothing to navigate the maneuver, it is used only to get benefit from ground speed mini function when you use managed speed. Airbus doesn't prohibit circling without activating secondary flight plan to opposite threshold but in latter case selected speed shall be used instead of managed. Like on any normal airplane circling is described in therms of headings and timings and not by NAV via pilot created PBDs.
The situations was further aggravated as captain turn the heading knob but didn't pull it and autoflight remained in NAV. This Bus feature (pull knob to switch to selected guidance) is really confusing and it's happened to me several times just to rotate and not pull noticing this error only by FMA readout. Being under stress captain rotated heading to 086 (as stated in the report) - too much to the left to intercept final - because airplane didn't do what he expected, so he continued to rotate heading bug up to 086. Finally, when he realized mistake he pulled heading knob and that's why airplane started right turn instead of left (to the shortest direction).
That's what I can imaging reading the report (IMHO).
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TMF - yes, I read it that way and thanks for explaining the Sec FPL function - which I see as a distraction to a visual manouevre.
I am still unable to understand WHAT the FMS was navigating on when NAV was selected. Assuming it needs waypoints (as per Boeing) then why was there a waypoint in that direction and what was it?
I am still unable to understand WHAT the FMS was navigating on when NAV was selected. Assuming it needs waypoints (as per Boeing) then why was there a waypoint in that direction and what was it?
Controversial, moi?
This Bus feature (pull knob to switch to selected guidance) is really confusing and it's happened to me several times just to rotate and not pull noticing this error only by FMA readout.
Irrespective of the CRM issues previously discussed it is plain the captain was either subtly incapacitated or overloaded and confused. In high workload situations if confusion occurs the one thing you need but do not have is time to sit back and analyse the situation.
Despite the alleged bad atmosphere on the flight deck I would suggest that had the FO been situationally aware and been demonstrative in declaring he had control, what he was doing and why (i.e. 'I have control, turning left/right away from the hills, climbing to x feet') the captain would probably have acquiesced fully aware he had personally lost the plot.
What actions he took when he had composed himself or once on the ground is open to debate.
BOAC: As Ten Miles Final also posts - Managed NAV should NOT BE USED for a circle to land which is by definition a visual manoeuvre ----- however there has been a creeping trend amongst the "magenta line" generation to self build plans for these manoeuvres via PBD waypoints. The captain may have done this and then re-engaged NAV ( ie. managed nav. ) having done this if he then simply rotated the heading bug without then pulling it the aircraft would have continued in NAV longer than he anticipated.
A more usual use of the SEC FLT plan would be to give the correct GSmini reference and perhaps an extended certreline to avoid a flythrough.
I personally deplore the trend towards the view that since NAV is updated so accurately by GPS that it is OK to use it instead of looking out the window. Some youngsters are going to be in for a shock when they circle in a snowstorm and then have a map shift!! Still, us dinosaurs are in retreat!
A more usual use of the SEC FLT plan would be to give the correct GSmini reference and perhaps an extended certreline to avoid a flythrough.
I personally deplore the trend towards the view that since NAV is updated so accurately by GPS that it is OK to use it instead of looking out the window. Some youngsters are going to be in for a shock when they circle in a snowstorm and then have a map shift!! Still, us dinosaurs are in retreat!
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Meikleour
Agree with you - as far as GPS primary airplane is able to track very accurate, so we would be earning additional benefits staying in NAV (or tracking green dashed line in heading). Also useful for RNAV visual like in TLV.
I saw the video by RYR when downwind and final turn during circling on 737-800 is done referencing to map on ND end even changing bank angle selector on final turn to intercept inbound course very precisely.
I used to look for crosscheck to ND map from time to time when making final turn on visual approach.
Agree with you - as far as GPS primary airplane is able to track very accurate, so we would be earning additional benefits staying in NAV (or tracking green dashed line in heading). Also useful for RNAV visual like in TLV.
I saw the video by RYR when downwind and final turn during circling on 737-800 is done referencing to map on ND end even changing bank angle selector on final turn to intercept inbound course very precisely.
I used to look for crosscheck to ND map from time to time when making final turn on visual approach.