Distracted crew let Q400 descend towards terrain
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Hikoushi Post
Now that is the kind of post that helps aviators on this site to enhance their knowledge using the experience of others. Learn from the mistakes of others who are kind enough to share it with you. Do not insist on making your own!!
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OK...
1. Change of data source causes mode deactivation.
2. loss of mode causes unintended flight path
It seems the crew were distracted by the abnormal, so the flight path was not monitored, and therefore deviation not spotted until GPWS. Obviously I think the CRM fell apart in regards to this.
The report also refers to them not noticing the mode deactivation or monitoring the FMAs. Now, is it being suggested that the mode deactivation should have been spotted as a matter of routine scan? if so, I disagree. Yes, in general routine scanning should pick up mode changes, I don't dispute that, but in this case the mode change shouldn't have come as a surprise.
I'm not familiar with the Q400, either it's avionics or checklists, so the following terminology may be wrong, but the gist of what Im saying should be valid. Comparable aircraft I have flown have had similar behaviours. I.e. Changing data sources might result in a mode change. Thus, changing a data source is an event of equal gravity to making a flight mode selection.
So it should have a thought process to match:
What modes have I got?
What should happen when I make these selections?
(make the selections)
Are the modes as I expected? (if not, why?)
Is the other pilots mental model of the current modes the same as mine? If not, which (if either!) of us is right?
In this case the very act of reaching for the air data selector should have triggered the knowledge that it would disarm the alt capture, and a wise PNF would verbalise that knowledge IMHO. 'this will kill your vertical modes' or similar.
So to me this doesn't just speak of a crm breakdown, but also weak initial tech training and/or poor recurrent training. Surely an ADC failure should be part of the recurrent sim training?
Please note I'm pointing the finger less at the crew than the training, but also at the industry in general.
1. Change of data source causes mode deactivation.
2. loss of mode causes unintended flight path
It seems the crew were distracted by the abnormal, so the flight path was not monitored, and therefore deviation not spotted until GPWS. Obviously I think the CRM fell apart in regards to this.
The report also refers to them not noticing the mode deactivation or monitoring the FMAs. Now, is it being suggested that the mode deactivation should have been spotted as a matter of routine scan? if so, I disagree. Yes, in general routine scanning should pick up mode changes, I don't dispute that, but in this case the mode change shouldn't have come as a surprise.
I'm not familiar with the Q400, either it's avionics or checklists, so the following terminology may be wrong, but the gist of what Im saying should be valid. Comparable aircraft I have flown have had similar behaviours. I.e. Changing data sources might result in a mode change. Thus, changing a data source is an event of equal gravity to making a flight mode selection.
So it should have a thought process to match:
What modes have I got?
What should happen when I make these selections?
(make the selections)
Are the modes as I expected? (if not, why?)
Is the other pilots mental model of the current modes the same as mine? If not, which (if either!) of us is right?
In this case the very act of reaching for the air data selector should have triggered the knowledge that it would disarm the alt capture, and a wise PNF would verbalise that knowledge IMHO. 'this will kill your vertical modes' or similar.
So to me this doesn't just speak of a crm breakdown, but also weak initial tech training and/or poor recurrent training. Surely an ADC failure should be part of the recurrent sim training?
Please note I'm pointing the finger less at the crew than the training, but also at the industry in general.
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PAX,
You clearly state you are a passenger so the only thing you are qualified to comment on is seat comfort.
I'm not attacking Flybe or their pilots (I know a few), but for operational or technical reasons they do pop up alot on AAIB. The one that almost hit the mast at aberdeen, the one that scrapped the tail.... etc etc. Fact is the Q400 is in there often.
Nor would I suggest it couldn't happen to me, it can happen to anyone at anytime.Wasn't it the captain of the titanic who stated the day before it sunk he had never had any incidents in 40 years.
Keep telling myself the mantra aviate-navigate-communicate all the time, and that basic premise stands good.Do not be distracted.
You clearly state you are a passenger so the only thing you are qualified to comment on is seat comfort.
I'm not attacking Flybe or their pilots (I know a few), but for operational or technical reasons they do pop up alot on AAIB. The one that almost hit the mast at aberdeen, the one that scrapped the tail.... etc etc. Fact is the Q400 is in there often.
Nor would I suggest it couldn't happen to me, it can happen to anyone at anytime.Wasn't it the captain of the titanic who stated the day before it sunk he had never had any incidents in 40 years.
Keep telling myself the mantra aviate-navigate-communicate all the time, and that basic premise stands good.Do not be distracted.
Fit like min?
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"I'm not attacking Flybe or their pilots (I know a few), but for operational or technical reasons they do pop up alot on AAIB. The one that almost hit the mast at aberdeen, the one that scrapped the tail.... etc etc. Fact is the Q400 is in there often."
If you are referring to the incident that I think you are referring to, that was i. Brymon, ii. a DHC8-300 & iii. 1998.
Not aware of any other instance of a plane approaching Aberdeen coming close to that mast, be it Flybe or anyone else.
If you are referring to the incident that I think you are referring to, that was i. Brymon, ii. a DHC8-300 & iii. 1998.
Not aware of any other instance of a plane approaching Aberdeen coming close to that mast, be it Flybe or anyone else.
Last edited by Richard Taylor; 26th Jun 2012 at 16:07.
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Fade to Grey.
Aviate, Navigate, communicate.
Dead right.
But please mate, that comment to Pax was wrong. That type of comment does none of us any good. So what if he's a spotter. He has an interest, and going by past comments of his he does have a clue. If not, at least he asks. The least any instructor would ask
Aviate, Navigate, communicate.
Dead right.
But please mate, that comment to Pax was wrong. That type of comment does none of us any good. So what if he's a spotter. He has an interest, and going by past comments of his he does have a clue. If not, at least he asks. The least any instructor would ask
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Jazz - i don't see that your point relates to me, that's up to BALPA if they want opinions from passengers,whoever.
Adam - yeah, fair enough I was a bit harsh. But PAXboy accuses me of a 'snap judgement' , I'm not judging anyone, but I maintain thats hours/age is generally a reliable indicator of background.
Everyone's a bit touchy round here.
Adam - yeah, fair enough I was a bit harsh. But PAXboy accuses me of a 'snap judgement' , I'm not judging anyone, but I maintain thats hours/age is generally a reliable indicator of background.
Everyone's a bit touchy round here.
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yeah, fair call mate. But just remember, everyone is allowed their opinion. Snap judgement aside, it is no less than ours in retrospect. Our opinion is based from experience. Some know more, others less. most if not all are relevant, but the jems are from those from the outside. I always listen to the pax, it is those who we serve no?
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For those that missed it take a look at post 18. That is probably the hardest thing for the 300 hr guys to do, drop down a notch or two in automation even if it means hand flying to make the job simpler. Too much programing and monitoring programing at low altitude can really screw up your situational awareness with a last minute runway change.
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As an SLF I have read PPRuNe for years but never commented - not my place to get in the way perhaps. However, this time.
OK, this forum does have its share of un-informed or un-thought through comments often from people who are (hopefully) not in the industry and at best may only be qualified to evaluate seat comfort.
However not all PAX are telephone sanitisers, some are well qualified to have opinions on or even insights into the issues discussed. Some work with technology and with the use of technology by people at similar levels to you. Some may have friends and family in the industry. Some will be well informed across the training and resource management issues you face. Some may actually have useful input.
My own interests involve training people to use (and understand) the increasingly complex "labour saving technologies" that we find in science and industry today. This is of real significance to the airline industry today with workload and knowledge/understanding issues sometimes causing it all to hit the fan when the old swiss cheese starts to wobble.
I do wonder what you all think of the automation of flying today where as systems become more simple on the outside they may become far more complex on the inside making it harder to understand what the plane is doing or complaining about now. And we certainly have had some very tragic outcomes as a result.
Is it getting harder for under-experienced or under-trained pilots to cope when push comes to shove?
Unfortunately flying is an industry which is seldom measured by its daily successes of which there are millions but by its few failures.
Anyway, for those of you who are doing the "good work", thank you and keep it up.
OK, this forum does have its share of un-informed or un-thought through comments often from people who are (hopefully) not in the industry and at best may only be qualified to evaluate seat comfort.
However not all PAX are telephone sanitisers, some are well qualified to have opinions on or even insights into the issues discussed. Some work with technology and with the use of technology by people at similar levels to you. Some may have friends and family in the industry. Some will be well informed across the training and resource management issues you face. Some may actually have useful input.
My own interests involve training people to use (and understand) the increasingly complex "labour saving technologies" that we find in science and industry today. This is of real significance to the airline industry today with workload and knowledge/understanding issues sometimes causing it all to hit the fan when the old swiss cheese starts to wobble.
I do wonder what you all think of the automation of flying today where as systems become more simple on the outside they may become far more complex on the inside making it harder to understand what the plane is doing or complaining about now. And we certainly have had some very tragic outcomes as a result.
Is it getting harder for under-experienced or under-trained pilots to cope when push comes to shove?
Unfortunately flying is an industry which is seldom measured by its daily successes of which there are millions but by its few failures.
Anyway, for those of you who are doing the "good work", thank you and keep it up.
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Well done, Jazz Hands
- you just made one of the threads in Jet Blast.
If you think passengers know naff all, that's fine, but you're walking on thin ice if you then start leveraging those same ill-informed views to push your own agenda.
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(Taken from the report on page 1):
"It adds that the crew did not follow standard procedures after the terrain warning."
What is the story here?? Seems to me like this could be a FAR bigger issue... anyone could make the initial mistake - but did they not respond properly to the gpws?
"It adds that the crew did not follow standard procedures after the terrain warning."
What is the story here?? Seems to me like this could be a FAR bigger issue... anyone could make the initial mistake - but did they not respond properly to the gpws?
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Squawking PAX,
I'll give you my pence worth. Reliance on automatics has been around for years, this is the way modern airliners are flown.
I think,maybe, too much fuss is made about it. To be honest there are alot of occasions where you don't want to hand fly anyway - departing LHR ? far too much happening, above 10000 - company doesn't allow it . Descending into XXX after 8 hr flight - too knackered now. Ok , departing xxx - er, no high terrain, and dodgy ATC.....To be honest I don't need a large proportion of my capacity taken up with raw data/hand flying, I have other things to do, even moreso from LHS. We must face the facts that we are not really 'pilots' in the conventional sense anymore.Wanna hand fly ,go hire an extra at the weekend.
Now that's not to say I don't want to stay current in hand flying, but that's mainly for my own reassurance - I've found when people don't do it for a while they become fearful of cocking up. Not really for the 'what ifs' because to be honest, the boeing I fly has 3 autopilots and not once have I been in the boat of having none serviceable in 9 years on type.That's not to say it would never happen but into the realms of low probability I think.
Slightly off track, but IIRC the MEL says you can dispatch with no A/Ps, but with my (last) company ban on hand flying above 10k it ain't gonna happen is it ?
I'll give you my pence worth. Reliance on automatics has been around for years, this is the way modern airliners are flown.
I think,maybe, too much fuss is made about it. To be honest there are alot of occasions where you don't want to hand fly anyway - departing LHR ? far too much happening, above 10000 - company doesn't allow it . Descending into XXX after 8 hr flight - too knackered now. Ok , departing xxx - er, no high terrain, and dodgy ATC.....To be honest I don't need a large proportion of my capacity taken up with raw data/hand flying, I have other things to do, even moreso from LHS. We must face the facts that we are not really 'pilots' in the conventional sense anymore.Wanna hand fly ,go hire an extra at the weekend.
Now that's not to say I don't want to stay current in hand flying, but that's mainly for my own reassurance - I've found when people don't do it for a while they become fearful of cocking up. Not really for the 'what ifs' because to be honest, the boeing I fly has 3 autopilots and not once have I been in the boat of having none serviceable in 9 years on type.That's not to say it would never happen but into the realms of low probability I think.
Slightly off track, but IIRC the MEL says you can dispatch with no A/Ps, but with my (last) company ban on hand flying above 10k it ain't gonna happen is it ?
Give the fellows that put together the assembly of parts collectively known as Q400 Collier trophy, for their lovechild has successfully turned "You fly like an autopilot" from a compliment to an insult.
I'm not talking about that particular (soon to be two year old) incident, just the "normal" everyday operation.
I'm not talking about that particular (soon to be two year old) incident, just the "normal" everyday operation.
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If you are as comfortable hand flying as programming an autopilot, sure let the autopilot do it. If you are uncomfortable disconnecting the autopilot and autothrottle then it is time to do some hand flying so you are. Do it where you can get up to speed without getting behind the aircraft however. Not in a terminal area.
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As a reader of this forum for years, it never fails to amuse me the crap spoken! I liken it to reading a paper, if you have ever been involved in a story you will know how untrue a newspaper article reflects it! Prune is similar it's become a joke! Shame as used to be a Good portal to share, but from now on I don't think I will bother anymore as its become a joke! For the record airline captain nearly 20 years online!, I met danny once and thought good on you! Where did the ideals go? Shame!!!!
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Burpbot - don't believe it . Trolling ?
738 - You can't just 'do it' - I'll say it again company SOPs don't allow it. Are you familiar with the idea of SOPs ?And the rest is not bla bla bla, the rest is what will get you nicked on the QAR.
I am somewhat concerned about your slapdash approach, mate.
I hear of another airline where there are no hand flying limits, so some young chap decided to fly all the way to XXX by hand. Bloody great idea (not), like I want to spend 70 % of my time monitoring him
738 - You can't just 'do it' - I'll say it again company SOPs don't allow it. Are you familiar with the idea of SOPs ?And the rest is not bla bla bla, the rest is what will get you nicked on the QAR.
I am somewhat concerned about your slapdash approach, mate.
I hear of another airline where there are no hand flying limits, so some young chap decided to fly all the way to XXX by hand. Bloody great idea (not), like I want to spend 70 % of my time monitoring him
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B738 driver: I agree with you all the way. Our major airline had no sop's about handflying. The only airlines that would need those SOP's would be for pilots that couldn't hand fly. Needing an autopilot to fly your aircraft is scary. It should be a workload reliever, not a substitute for a competent pilot.
90 % of my approaches were hand flown because the last 6 years I flew into TGU in Honduras and you had to hand fly. Letting automation fly your airplane because it is safer in VMC conditions means you are not up to the task and should sharpen your hand flying skills. SOP's for automation only airlines probably hire low time pilots out of Embry Riddle that know how to program a computer but can't hand fly well.
Thank God the older airlines still have pilots that can fly without computers. Most haven't hired since 911. I saw the last group get furloughed two weeks after 911 and they aren't back yet. Sad.
90 % of my approaches were hand flown because the last 6 years I flew into TGU in Honduras and you had to hand fly. Letting automation fly your airplane because it is safer in VMC conditions means you are not up to the task and should sharpen your hand flying skills. SOP's for automation only airlines probably hire low time pilots out of Embry Riddle that know how to program a computer but can't hand fly well.
Thank God the older airlines still have pilots that can fly without computers. Most haven't hired since 911. I saw the last group get furloughed two weeks after 911 and they aren't back yet. Sad.
