Distracted crew let Q400 descend towards terrain
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Distracted crew let Q400 descend towards terrain
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Distracted crew let Q400 descend towards terrain
By: David Kaminski-Morrow London
Pilots of a Flybe Bombardier Q400 allowed the aircraft to drift below its glidepath after becoming distracted by an electrical failure that had affected the captain's displays.
It descended to about 700ft (210m) above terrain, while still 8nm (15km) from the runway, before the ground-proximity warning system ordered the crew to pull up.
The Q400 had been conducting an instrument landing system approach to Exeter's Runway 26 on 11 September 2010. Its autopilot was engaged and the aircraft had been descending to a selected altitude of 2,600ft.
At about 3,300ft the engine display indicated a processor failure. While the first officer's primary displays remained normal, the captain's showed absent speed bugs and minimum descent altitude setting.
The captain tried various techniques to restore the display, including switching the air-data computer source before reverting to the original when this failed to have an effect. However, the UK Air Accidents Investigation Branch says that this reversion, by design, cancelled all previously-selected flight-director modes - including the altitude selection. This deactivation "went unnoticed" by the crew, it adds, and the effect was to allow the Q400 to descend through its cleared level.
"While attempting to resolve an unfamiliar failure which had resulted in unexpected cockpit effects, both pilots became distracted from the primary roles of flying and monitoring the aircraft," it says.
Having failed to capture the cleared altitude the aircraft continued to descend until the ground-proximity warning system issued a terrain alert - prompting the two pilots to look up - followed a few seconds later by a "pull up" command.
There had been no action to correct the flightpath before the warning, suggesting the pilots were "not aware of the extent of the deviation" and were not monitoring the Q400's track or its flight-mode annunciator, says the AAIB.
It adds that the crew did not follow standard procedures after the terrain warning.
The AAIB points out it has investigated two previous incidents involving Flybe Q400s, in which the aircraft descended below their cleared level during approach owing to inappropriate mode selection and inadequate annunciator monitoring.
Flybe, which gave the pilots additional training before returning them to duty, has since introduced a new flight-operations monitoring programme involving observers in the cockpit.
Distracted crew let Q400 descend towards terrain
By: David Kaminski-Morrow London
Pilots of a Flybe Bombardier Q400 allowed the aircraft to drift below its glidepath after becoming distracted by an electrical failure that had affected the captain's displays.
It descended to about 700ft (210m) above terrain, while still 8nm (15km) from the runway, before the ground-proximity warning system ordered the crew to pull up.
The Q400 had been conducting an instrument landing system approach to Exeter's Runway 26 on 11 September 2010. Its autopilot was engaged and the aircraft had been descending to a selected altitude of 2,600ft.
At about 3,300ft the engine display indicated a processor failure. While the first officer's primary displays remained normal, the captain's showed absent speed bugs and minimum descent altitude setting.
The captain tried various techniques to restore the display, including switching the air-data computer source before reverting to the original when this failed to have an effect. However, the UK Air Accidents Investigation Branch says that this reversion, by design, cancelled all previously-selected flight-director modes - including the altitude selection. This deactivation "went unnoticed" by the crew, it adds, and the effect was to allow the Q400 to descend through its cleared level.
"While attempting to resolve an unfamiliar failure which had resulted in unexpected cockpit effects, both pilots became distracted from the primary roles of flying and monitoring the aircraft," it says.
Having failed to capture the cleared altitude the aircraft continued to descend until the ground-proximity warning system issued a terrain alert - prompting the two pilots to look up - followed a few seconds later by a "pull up" command.
There had been no action to correct the flightpath before the warning, suggesting the pilots were "not aware of the extent of the deviation" and were not monitoring the Q400's track or its flight-mode annunciator, says the AAIB.
It adds that the crew did not follow standard procedures after the terrain warning.
The AAIB points out it has investigated two previous incidents involving Flybe Q400s, in which the aircraft descended below their cleared level during approach owing to inappropriate mode selection and inadequate annunciator monitoring.
Flybe, which gave the pilots additional training before returning them to duty, has since introduced a new flight-operations monitoring programme involving observers in the cockpit.
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In the Q400 it doesn't take a processor failure to have you descending towards terra firma.
A single click on the pitch wheel while on the glideslope does, if unnoticed, the same.
Been there, done that...
A single click on the pitch wheel while on the glideslope does, if unnoticed, the same.
Been there, done that...
There had been no action to correct the flightpath before the warning, suggesting the pilots were "not aware of the extent of the deviation" and were not monitoring the Q400's track or its flight-mode annunciator, says the AAIB.
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Distracted crew let Q400 descend towards terrain
HELLO!:
"DOES ANYBODY HAVE CONTROL?"
(while passengers seating in 0A and 0B quarrel?)
http://www.pprune.org/rumours-news/4...-deck-row.html
https://www.newscore.com/
Incident: Flybe DH8D at Waterford on Jun 5th 2012, runway excursion during backtracking
http://www.dailyrecord.co.uk/2012/06...6908-23881832/
"DOES ANYBODY HAVE CONTROL?"
(while passengers seating in 0A and 0B quarrel?)
http://www.pprune.org/rumours-news/4...-deck-row.html
https://www.newscore.com/
Incident: Flybe DH8D at Waterford on Jun 5th 2012, runway excursion during backtracking
http://www.dailyrecord.co.uk/2012/06...6908-23881832/
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@ fade to grey
At least the incidents are reported - unlike many cases in the Medical or Shipping professions. I think I'm still proud my employer (not BE) has an "open" policy and any incidents are reported.
At least the incidents are reported - unlike many cases in the Medical or Shipping professions. I think I'm still proud my employer (not BE) has an "open" policy and any incidents are reported.
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We all practice for the major failures in the sim, this goes to show that even a small component failure, in itself not critical, can lead to another of the holes in the "Swiss Cheese" to line up.
It's a lesson that should be learned by all professional pilots, don't be seduced by the "it won't happen to me" syndrome...... however good you are, it just might!
It's a lesson that should be learned by all professional pilots, don't be seduced by the "it won't happen to me" syndrome...... however good you are, it just might!
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fade to grey
Generally low crew experience? I don't think that was a factor in this case. There's a hell of alot less experience in another major UK operator which we all know about, and Snigs is correct, you are only one flight away from your next incident so if we think it won't happen to us then think again.
Generally low crew experience? I don't think that was a factor in this case. There's a hell of alot less experience in another major UK operator which we all know about, and Snigs is correct, you are only one flight away from your next incident so if we think it won't happen to us then think again.
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The experience levels on the Q400 are currently high. This could have happened to the greatest 'ace' that contributes to pprune considering the machine that was involved - also what not appears to be mentioned is that I believe it was a CAVOK visual approach
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Tyreplug
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The experience levels on the Q400 are currently high. This could have happened to the greatest 'ace' that contributes to PPRuNe considering the machine that was involved - also what not appears to be mentioned is that I believe it was a CAVOK visual approach
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The experience levels on the Q400 are currently high. This could have happened to the greatest 'ace' that contributes to PPRuNe considering the machine that was involved - also what not appears to be mentioned is that I believe it was a CAVOK visual approach
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A more appropriate response which is unfortunately not trained as often as it should be in our modern, automation-dependent world would be the old "click-click, click-click". Those of us from before the MPL / G1000 generation learned to fly on aircraft with no "bugs" on the airspeed indicators; most of us learned to fly an ILS raw-data with a pair of crosshairs or maybe an HSI in more recent times. When flight directors, FMAs, speed and heading bugs etc go kittywompus on us we should still be able to "step down" the automation and handfly comfortably on basics. A missed approach is another safe option. It seems like these skills are discouraged in most SOPs and training departments these days, and that is a disservice to pilots who could benefit from maintaining those skills, such as this situation.
Have the chart in front of you. If you lose your G/S or ALT SEL on your FMA, turn it all off and fly the airplane like it was a very fast Seminole. This is how it should be trained and skill should be mandated. We have to log autolands to maintain currency in my company; why not mandate log at least one raw-data fully hand-flown approach (in VMC even!) every 90 days? Probably get laughed out of the building to bring that one up to a training department anywhere in the world these days, which is sad. If that were trained to proficiency, instinct, and recency to the extent autoflight is, these kind of incidents would decrease.
Never going to happen. Oh well, starting to show my age, I guess!
Have the chart in front of you. If you lose your G/S or ALT SEL on your FMA, turn it all off and fly the airplane like it was a very fast Seminole. This is how it should be trained and skill should be mandated. We have to log autolands to maintain currency in my company; why not mandate log at least one raw-data fully hand-flown approach (in VMC even!) every 90 days? Probably get laughed out of the building to bring that one up to a training department anywhere in the world these days, which is sad. If that were trained to proficiency, instinct, and recency to the extent autoflight is, these kind of incidents would decrease.
Never going to happen. Oh well, starting to show my age, I guess!
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A more appropriate response which is unfortunately not trained as often as it should be in our modern, automation-dependent world would be the old "click-click, click-click". Those of us from before the MPL / G1000 generation learned to fly on aircraft with no "bugs" on the airspeed indicators; most of us learned to fly an ILS raw-data with a pair of crosshairs or maybe an HSI in more recent times. When flight directors, FMAs, speed and heading bugs etc go kittywompus on us we should still be able to "step down" the automation and handfly comfortably on basics. A missed approach is another safe option. It seems like these skills are discouraged in most SOPs and training departments these days, and that is a disservice to pilots who could benefit from maintaining those skills, such as this situation.
As for the airline in question, my understanding is the autopilot on the dash 8 is so unuser friendly, full of latent errors, that pilots hand fly more often than most.
But as a general case for modern aviation, I see your point.
Last edited by VNAVPTH; 22nd Jun 2012 at 09:12.
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A very nice video. It's interesting to see it was filmed in 97 and yet the same message is having to be consistently repeated. Every SESMA review carries the same messages, along with recurrent check debriefs/learning points to the respective fleets.
I still have my copy of "What's it doing now?" issued by my company. It highlighted the differences in errors due to lower SA as a result of flying the glass cockpit version of the 737 as opposed to the trabbie (200). Those in the steam powered version had far higher levels of SA. But the technology was supposed to make it the other way round. Still to this day aircraft automatics get miss managed, due to over dependence at critical times, and less critical. Pilots are more out of the loop than ever due to 'bean counter style' Flt ops/safety policies implemented by some training regimes and the likes. Fancier versions of NOTECHS have been issued since, yet the training, whilst invaluable, gets left behind by back side covering policies that aim to ridicule pilots for making mistakes when the automatics were available. Yet when distractions with automatics engaged lead to Loss of SA and resultant errors, more blame is placed on pilots for forgetting to FLY THE AIRCRAFT. An interesting modern day conundrum, but one that does little for safety.
Ultimately it is incumbent on companies and individual to keep skill levels up and awareness at all times. Appropriate support for development of these skills is vital. Without appropriate policies and training support, AIRMANSHIP IS LOST.
I have read with interest the thread where line captains complain about having to 'train/babysit' new ab-initio pilots on the line. The best place for them to hone their skills is on the aircraft! They require the right supporting manager(CAPTAIN) to help guide them. In time they become 'in tune' with the aircraft and far better pilots. The simulator is no airplane! But then a C152 or PA 34 is no dash 8/ airbus or 737!
More emphasis these days is placed at the ab-initio level on not being heads down reprogramming the box at bust times! ANC and PPP are the keys for priorities. But as one young lad a few years back remarked, post event, when I asked him what colour the van beside the runway was ( you have already guessed where his attention was) "I was so used to doing it on Flt sim when I was getting ready to do my training, I wanted to prove I could do it in the real thing". He learnt a big lesson that day, so did I.
I still have my copy of "What's it doing now?" issued by my company. It highlighted the differences in errors due to lower SA as a result of flying the glass cockpit version of the 737 as opposed to the trabbie (200). Those in the steam powered version had far higher levels of SA. But the technology was supposed to make it the other way round. Still to this day aircraft automatics get miss managed, due to over dependence at critical times, and less critical. Pilots are more out of the loop than ever due to 'bean counter style' Flt ops/safety policies implemented by some training regimes and the likes. Fancier versions of NOTECHS have been issued since, yet the training, whilst invaluable, gets left behind by back side covering policies that aim to ridicule pilots for making mistakes when the automatics were available. Yet when distractions with automatics engaged lead to Loss of SA and resultant errors, more blame is placed on pilots for forgetting to FLY THE AIRCRAFT. An interesting modern day conundrum, but one that does little for safety.
Ultimately it is incumbent on companies and individual to keep skill levels up and awareness at all times. Appropriate support for development of these skills is vital. Without appropriate policies and training support, AIRMANSHIP IS LOST.
I have read with interest the thread where line captains complain about having to 'train/babysit' new ab-initio pilots on the line. The best place for them to hone their skills is on the aircraft! They require the right supporting manager(CAPTAIN) to help guide them. In time they become 'in tune' with the aircraft and far better pilots. The simulator is no airplane! But then a C152 or PA 34 is no dash 8/ airbus or 737!
More emphasis these days is placed at the ab-initio level on not being heads down reprogramming the box at bust times! ANC and PPP are the keys for priorities. But as one young lad a few years back remarked, post event, when I asked him what colour the van beside the runway was ( you have already guessed where his attention was) "I was so used to doing it on Flt sim when I was getting ready to do my training, I wanted to prove I could do it in the real thing". He learnt a big lesson that day, so did I.
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Tyreplug - Are you insane ? the Captain had 3000hrs total, 1500 on type and was 44 years old. I don't consider that alot of experience to be honest, and the age against hours indicates a 'career changer'.
I think low experience combined with a demanding crappy TP, multi sector hard fatiguing days are the main reasons the AAIB bulletin should be renamed 'Flybe monthly'.
Arctic , I know who you mean, but the FOs may be fresh off the money making schemes but the Capts have more than 3000 hrs ?...... Actually I don't know if you are talking about the low cost harp boys.
Calm down, I know this sort of thing happens to anyone, it's just it all seems to happen to Flybe more....
I think low experience combined with a demanding crappy TP, multi sector hard fatiguing days are the main reasons the AAIB bulletin should be renamed 'Flybe monthly'.
Arctic , I know who you mean, but the FOs may be fresh off the money making schemes but the Capts have more than 3000 hrs ?...... Actually I don't know if you are talking about the low cost harp boys.
Calm down, I know this sort of thing happens to anyone, it's just it all seems to happen to Flybe more....