Another look at the Ethiopean Airlines 737-800 crash at Beirut.

[Centaurus]

Many of us neither have the time or inclination to wade through aircraft accident reports. Especially the tedium of staring at a computer screen for page upon page. Yet we all know that in aviation we can often learn from another's experience.

In that context I strongly recommend a study of the Ethiopean Airlines Boeing 737-800 accident that occurred shortly after take off from Beirut on 25 January 2010. The subject has been discussed at length in Pprune.

Richard Aarons, the Safety Editor of the magazine Business & Commercial Aviation, is well known by those interested in reading his column Cause and Circumstance. In the March 2012 issue of B&CA he has written a first class description of this horrifying crash and the unbelievable absence of manual instrument flying ability displayed by the captain. If ever there was a case for airline managements to realise how vital it is for pilots to maintain hand flying skills in jet transports, then the story of Ethiopean Airlines Flight ET 409 written by Richard Aerons must surely convince them. All on board (90) were killed when the 737 hit the sea 63 degrees nose down at 407 knots just a few minutes after lift-off.

This is not an advertisement for B&CA and I hope the Mods reading this post understand that.

[captplaystation]

I guess the article is not available on line without a subscription, if anyone "were" to cut/paste, or anyone with the time type it out, I am sure we could all benefit.

[Tom!]

Also good article about it in this months issue of aero safety world. Free for download at Flight Safety Foundation: Home Page

[tbaylx]

I continue to be amazed that there are flight crew flying as professional pilots that cannot fly simple instrument departure and arrival procedures or even keep an aircraft straight and level on instruments. How many more crew members are out there that have no business in the pointy end of an aircraft?
As the number of aircraft worldwide continues to increase and the standards are lowered in a profession that is simply not that attractive anymore due to constant erosion of working conditions, makes me wonder how many more of these we'll see before something gets done about it. Guess as long as airlines are making somebody money it won't change.
I'm certainly picky about what airline i'll let my family fly on as a result of these types of accidents (ie. this one, turkish in amsterdam, any number of indonesian or indian incidents etc)

[stepwilk]

It's Richard Aarons, not Aerons.

[fireflybob]

tbalyx - I share your sentiments but I feel the underlying cause is lack of regulation.

At least in the USA in the wake of the Colgan accident there seems to be a more robust approach being taken there to up the standards.

Sadly this is obviously lacking in other parts of the world.

[Caboclo]

Tbaylx, do you let your family fly Air France?

[tbaylx]

Good question, up until a few years ago i would have said yes without question, as i would have for most Euro airlines (with the exception of Ryan Air, and nothing to do with crew competence, i just refuse to help MO make money in any way).

The Air France crash, while bringing to light a lot of questions, is inherently different than the Ethiopian one. AF 447 had systems failures that led to some pretty ambiguous indications, while Ethiopian managed to ball up a perfectly functioning aircraft due to the inability to fly it. Same with an awful lot of the Indian crashes and Indonesian incidents lately.

I guess I would have to say yes, believing that the vast majority of AF pilots are competent professionals with an appropriate regulatory oversight and generally decent crew training and checking standards. I'm not so sure the same can be said for a lot of other airlines worldwide.

[IcePack]

Lots of years flying crop dusters & reasonable time staring at instruments, so would have thought the pf (capt) would have had more than adequate flying skills.
Just goes to show, flying has a habit of proving the obvious wrong. Awful thing to read. A disoriented crew on a dark dirty night. RIP

[Centaurus]

The reason for fast declining handling skills is simple. It starts from the first simulator session on the pilots first jet transport, although one could also argue the flying schools have a lot to answer for.

For example one major flying school in Australia operating the Cessna 172 and specialising in training students whose wealthy parents are funding their kid in the hope he will become a future airline pilot, now has lengthy checklists out of all proportion to the complexity (?) of a C172 with the student as Pilot Flying (PF) and his instructor as Pilot Monitoring (PM). How bloody sad is that sort of rubbish taught to a student who hasn't even gone solo.

Back to the first simulator session. From talking to countless airline pilots over the past 20 years, I have discovered that almost all started their first jet type rating training in the simulator with flight directors, autothrottles, FMC button pounding and of course the autopilot, ALL ON.

They had never flown a jet for Christ's sake but were up to their ears in automatics right from the start. The priority is all wrong. Is it any wonder that once these pilots are in the real aircraft, manual flying becomes not only something to be avoided, especially in IMC - but is regarded as almost lethal.

Someone said "Technology should be seen as an adjunct to commonsense or learned intelligence, not as an alternative." I'll go along with that.

Until simulator instructors start teaching new pilots - especially the straight into the right hand seat (second in command) cadets, how to fly raw data on instruments to a high standard - before gradually introducing the automatic features, then accidents of the Beirut variety will continue to be inevitable

[aerostatic]

Until simulator instructors start teaching new pilots - especially the straight into the right hand seat (second in command) cadets, how to fly raw data on instruments to a high standard - before gradually introducing the automatic features, then accidents of the Beirut variety will continue to be inevitable

Good point and I fully agree. Keep in mind though that whilst simulator instructors may have some latitude in the training content dished out, mostly it is highly prescriptive.

[sabenaboy]

Originally Posted by Centaurus

Until simulator instructors start teaching new pilots - especially the straight into the right hand seat (second in command) cadets, how to fly raw data on instruments to a high standard - before gradually introducing the automatic features, then accidents of the Beirut variety will continue to be inevitable

I don't think the low time cadets are the problem, but more likely the training department of the companies involved. My company also hires the low time cadets fresh out of flight academy. Most of them do a great job at handflying, once they're released on line.
Here's what I wrote about it in an other post.

In my company it's done like this: Starting in the type-rating sim sessions the F/O's in training are learned to fly the Airbus manually (A/P, F/D & A/THR off) on many occasions whenever the exercise permits it. (And, for training, having one engine out is NOT a good reason to keep the A/P on. ) Then, during base training they'll fly a few touch and go's, again without the automatics. Later on, during the initial line training, they will be asked to fly manual raw data approaches, whenever the conditions permit it. Believe me, once they're fully released on line they'll handfly the A320 pretty well, or ... they won't be released on line.

Unlike many others my company encourages pilots to keep their handflying skills up to date. Most of the time, I don't have to suggest my F/O's to turn the automatics off. they will have asked me before if they can. More often it happens, especially with the newly released kids, that I have to suggest them that it would be wise to fly with the automatics on when the metar warns us about low clouds and moderate visibility or when flying into a busy airport we are not familiar with! It's not they are not smart enough to know that, it's just that they were so used to raw date flying during their training, that using the automatics for approach has become the exception, rather then the rule.

I'll admit that sometimes those new F/O's are not so great in using the automatics. For instance, the first time they have to intercept a G/S from above with the A/P, they will often have a problem. Not amazing, they've trained it once in the sim and then they were expecting it! So confronted to this situation these guys (and girls) will disconnect the A/P when it captures the initial approach alt before the G/S iso using the Airbus procedure for this. (dialling the altitude up and using V/S to get to the G/S.) Oh well, manually intercepting the slope and then re-engaging the A/P gets the job done just as well and it gives me something to talk about during a friendly post-flight debrief.

There is really no excuse for Airlines who forbid their pilots to keep their raw data handflying skills up to date.

[The Ancient Geek]

Simulator training has its limits, concentrating on keeping all of the instruments showing the correct results. What is missing is the ability to respond when something goes wrong and the instruments show the unexpected. There is no substitute for proper training in recovery from unusual attitudes and this is missing from most curriculums.

Many years ago an aerobatics instructor spent a week taking me up under the hood, throwing it all over the sky and then saying "you have control" just as my breakfast was about to make a bid for freedom. Scary as hell but that week taught me more about flying than any fancy modern simulator could possibly do.

Ask yourself, when it all goes suddenly wormy could you figure it out without any outside reference ?.

[jet-lover]

sabenaboy

Sabenaboy, u r absolutely right that it’s very hard to blame cadet pilots. I m talking this from self experience of being one of thoseEthiopian cadet plots who was put on a highly automated machine like the 737 merely few months after graduating from training school with no other flight experience other than the 250 hrs of 40 yr old C172’s. the whole transition training was a huge rush mainly because ET was running short of flight deck crews on the 737’s. indoctrination class, which was common training for previous batches were skipped and to our amazement even some of us didn’t do any observation flight. I saw the cockpit for the first time on my first simulator training day. Before that, all we know was pictorial representation on the cockpit in our computer based class ( CBT ). I still remember I had no idea of how to fasten and unfasten the five point seatbelt on the 1st simulator session since the C172’s seat belt is three point seat belt. While I was expecting my simulator training to start after a month, I was given one day notice to start because there was rescheduling after adding more shifts for simulator sessions. So my partner, who is a fresh graduate like me, and me had to spend whole night memorizing the emergency procedures and spit it out first thing in the morning on our training. but once we finished the simulator training, we were able to retain only few of those critically important procedures including the all too important recall items.
So like I said, no indoctrination, no observation flight and straight to assisted first officer postion. On my first assisted flight, I had difficulty of finding some offices like flight operations planner and documentation office to change worn out or missing charts from charts folder. My 1st assisted flight was the day I saw a real cockpit, which as u all know, is significantly different than simulator cockpit.
Finally, there is the case of an established culture in ET which is cockpit authoritarianism. Imagine a cockpit of fresh cadet with the lowest self confidence with an abusive captain who feels like the creator and maker of all things under the sky. I can say almost more than 75 % of the captains r like this. This is not coincidence though. The behavior starts from what we see in training schools where most of the instructors r ex-air force generals and colonels who see a trainee with so much disrespect. So it’s pretty much clear that a pilot who goes through a training like this develops little or no CRM knowledge.
The entire operation of ET is disastrous. There were so many close calls which r quickly swept under the rug thanks to a puppet CAA. ET409 was a disaster waiting to happen. The whole case is partly political also and I don’t wanna go into that section. However, while it should ve bn ECAA who checks if operations r done according to regulation, the order comes from ET to ECAA to tick the box and give approval on everything. ET is one of the few gov’t owned institutions who bring in large profit in the desperately needed hard currency so no wonder that the case of ET409 became political issue with Lebanon.
*** excuse mu grammar and spelling since English is my 2nd language.

[ATC Watcher]

Back to the original Thread: just finished the report and I am wondeing something ( curiosity ) : before I start , I have no experience whatsoever on B737 , nor Airbus, 90% of my flying hours were and still are done manually on one engine or less.

When I started flyin in the late 60s , my (jet trainer) military instructor told me that when faced in an upset situation, during aerobatics or during a dogfight: " hands off the controls, reduce power and the aircraft will recover on its own, or come to a position easy to recover. It is the wrong control inputs that will kill you, not the aircraft". This was true on this perticular aircraft type, perhaps not on all types.

Incidentally I tried this a couple of years ago on a high performance glider , (which has a tendency to start spinning violently without warning when flying disymetrical) and it worked very well. I know that this also apply to the Aerobatic aircraft I flew ( CAP10, CAP231 )but never tried it , but not sure if this works on a modern Extra or a Sbach though... I also would not recommend to do this below 2000ft.

My question is , does this also apply to a Boeing 737 ? ( or an Airbus 330 * )

If yes, is this part of the upset recovery training ? Just curious.

(*) I was told by an AI factory pilot that in case of AF447 if the pilots had not done anything ( i.e not touch the controls) the aircraft would have come out of this despite AP off.

[captjns]

I've flown with many f/o'swho came through on the cade program in Euroland and in Asia.

My departures and arrivals from quiet airports are flown manually without any automation The last bit of automation to be turned off are the Auto-throttles after flap retraction. Most of the lassies and laddies jump at the opportunity to fly the jet with all the automatics off after they've observed me doing the same. After all, how many C152s has anyone flown with an auto-throttle or flight director. Well, I can attest, in 1976, an avionics guru who owned a C-152 had an old Bendix FCS 810 FD system in his plane. Amazing I said

I enjoy letting them go through the paces of what real flying is about. On a typical rostered week which includes an average of 20 sectors, I fly perhaps 2. It's incredible the improvement I observe from their first sector of the day to the last. It's even better observing their reactions and smiles and well deserved compliments from me on their radical improvement. Within a couple of days, their landings are wihtin 500' of the touch down zone and center line.

I stress and demonstrate the importance of situation awareness. Makes not difference if I am line training, or not, maps are opened and used... not to block out the sun... that's what newspapers are for. Nearest suitable airport available are known should an unwelcome emergency crop. Navs are tuned so current position can be readily identifed. Keep their minds working by discussing what if scenarios. They learn very quickly how the FMC is useless in most situations for descent planning when the entire STAR is not flown. They observe descending at 330kts in the NG may keep them above the profile.

IMHO, my feeling is that automation can be the enemy of the up and coming pilot. The automation lures one curiosity. Always seems to work… and that one day while tooling around in the muck… total system failure… the enemy may win the out comeif the pilot is not up on their flying skills, or situational awareness.

I don’t mind if an airline encourages pilots to take full advantage of all the aircraft’s automation so that workload is reduced. The automation, in most cases reduces level busts and navigation errors. That’s a good recommendation, especially during high work load environments and busy terminal areas. However these same airlines do not promote hands on practice to maintain proficiency in the same robust manner as they recommend the use of the automation.

At the end of the day, there is not one simulator in the world that duplicates, nor replace the real world of flying, learning, actual experiences, building one’s skills and confidence.

[Centaurus]

excuse mu grammar and spelling since English is my 2nd language.

Jet-Lover. Nothing wrong with your grammar. You expressed yourself most clearly. Full marks for giving readers the benefit of your experience in Ethiopean Airlines as a cadet. Rarely do readers get such a direct description of what happens in the real world.
The God like flight deck personalities you describe, are in most airlines one way or another. The problem is more common in those countries where the military have a significant presence politically and their pilots run the airline. Long time Pprune readers will know which operators we are talking about.

In another Pprune forum a correspondent wrote:
(Edited for brevity). "Crew Resource Management (CRM) is a fraud...does anyone really believe that a pilot who is rude, stubborn or prone to cause conflicts in a cockpit is going to modify his attitude because of CRM? And, if he is a captain, he is going to listen more to his first officer - and vice versa? Is the pilot who tends to cower, going to become more assertive? No way. Perhaps CRM will have some effect on five-year-olds - but not on normal adult".

Countless CVR recordings over the years have revealed the autocratic attitude of the captain to be a contributory cause of an accident. Ethnic culture also plays its part in accidents.

Sabena Boy: Thank you for that enlightened reply. It is heartening to know that there are still pilots out there who are prepared to take the trouble of training their subordinates on manual flying skills.

[Northbeach]

Excellent point raised; worthy of more thought.

Centaurus, IcePack, Captplaystation & other admired members, I would like to focus on IcePack’s comment below and would appreciate your thoughts on the subject raised. Specifically how does a man in his 40s with > 10,000 hours including agricultural flying and a healthy amount of IMC end up in the Mediterranean? I would have thought that his background would have prevented this.

Lots of years flying crop dusters & reasonable time staring at instruments, so would have thought the pf (capt) would have had more than adequate flying skills.
Just goes to show, flying has a habit of proving the obvious wrong.

This accident reminds me of a Kenya Airways 737-800 that also came to grief shortly after departure at night with weather in the area.

I will say this about the 737; for the autopilot to engage you must be in stable trimmed flight (to a greater degree than the other T-category jet I spent a decade on). If one is flopping about the sky, like a fish out of water, the autopilot is not going to “save” you because it will not engage.

I look forward to your enlightening comments!

Respectfully,

Northbeach

[captplaystation]

Quite possibly Flash Airlines in Sharm el Sheikh too.

[sabenaboy]

Originally Posted by odericko2000

Interesting my post is pulled down while a phony one like jetlovers is still on

Odericko, I've read your first reply which was removed. It contained abusive language and the tone of your message was very impolite. I'm not amazed at all it was removed!

I've checked Jetflyer's previous messages. Apparently he has been involved with ET before and is now flying in Indonesia. I didn't find any abusive language in any his messages.

After reading his other messages, I find that his messages have more credibility then your contribution to this thread.