Lionair plane down in Bali.
From the current evidence on PPRuNe there is a good possibility that the cause of the Lion Air accident will be found to be the failure of the captain to conduct a safe go-around after losing all forward vision due heavy rain at or below the MDA. Where the actions of his first officer will come into the equation, has yet to be revealed.
Originally Posted by Smiling Monkey
It has been suggested in this thread from 'inside information' that the F/O retracted the flaps to 15 degrees without being commanded by the Captain, who we assume was now the PF. If that's not a failure in CRM, or Multi-Crew Coordination, then I don't know what is.
Would you really expect the crew to have a committee meeting (good CRM) to discuss what the FO had just done? Of course not. CRM is working together to solve a problem/FOs being empowered to speak up/Captains listening to their crew. However, one of the most basic requirements of good CRM is that each member involved is technically skilled in his/her job. If someone stuffs up in the hypothesised manner and the aircraft crashes immediately, it's not a CRM failure, it a technical skills failure.
Note: I am in no way implying that the Lion Air crew made any errors. My comments on CRM are general in nature using the example mentioned.
Not selecting go-around thrust would have to be high up on the list of possible causes.
Regarding the rumour that the FO may have selected F15 uncommanded, I am reminded of various suggestions made on a previous topic of what to do if your captain was determined on continuing with an unsafe approach. It may even have been the one about the Air India Express crash where an experienced Indian FO was paired with a highly experienced european and everyone was killed.
Forcing matters by calling go-around and starting the go-around actions was, if I remember correctly, one idea from certain quarters. Selecting flaps 15 is of course not the first action, but on the 737 it does come after setting go-around thrust and before 'positive climb gear up'. In the best traditions of pprune this is of course all rumour and speculation. But hopefully we will find out reasonably soon what really happened and can learn something useful.
Regarding the rumour that the FO may have selected F15 uncommanded, I am reminded of various suggestions made on a previous topic of what to do if your captain was determined on continuing with an unsafe approach. It may even have been the one about the Air India Express crash where an experienced Indian FO was paired with a highly experienced european and everyone was killed.
Forcing matters by calling go-around and starting the go-around actions was, if I remember correctly, one idea from certain quarters. Selecting flaps 15 is of course not the first action, but on the 737 it does come after setting go-around thrust and before 'positive climb gear up'. In the best traditions of pprune this is of course all rumour and speculation. But hopefully we will find out reasonably soon what really happened and can learn something useful.
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Has anyone called attention to the similarities between the Polish President's flight and failure to go around with the Bali splashdown? The pressures to continue an approach despite unable to visually acquire the runway below decision height....if pilots worry about being called in for tea and biscuits every time they have to go around, part of the blame in both accidents must be squarely placed on the organisation.....
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Lomapaseo
I dunno.... Seems the point that maybe both eng's were drowned after joining the GS, due possibly the skippers failure to set up properly for hvy rain, could also be a distinct possibility, and as worthy of inclusion in this thread as other comments on p2f, etc.. FDR will prove or disprove this. It sure would explain what was reported concerning the uninterrupted descent to the water if in fact that is true.
I dunno.... Seems the point that maybe both eng's were drowned after joining the GS, due possibly the skippers failure to set up properly for hvy rain, could also be a distinct possibility, and as worthy of inclusion in this thread as other comments on p2f, etc.. FDR will prove or disprove this. It sure would explain what was reported concerning the uninterrupted descent to the water if in fact that is true.
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This applies in so many disciplines which deal with critical incidents in real time as opposed to virtual reality minus experience. I have kept your post and will use it in my discipline.
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As someone pointed out earlier, the surfer dude who went to the rescue seemed to be suggesting that the first he knew of the plane's presence was the splash as it hit the water.
If this is to believed then the engines were either out or at or just above idle. A high bypass engine spools up in less than 6 seconds so even a partially successful attempt at a go around would be making a hell of a racket before it hit the water. :-(
Am I right in thinking we haven't seen any pics of the post-crash engines yet?
SoS
If this is to believed then the engines were either out or at or just above idle. A high bypass engine spools up in less than 6 seconds so even a partially successful attempt at a go around would be making a hell of a racket before it hit the water. :-(
Am I right in thinking we haven't seen any pics of the post-crash engines yet?
SoS
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Hello Radken,
The newer cfm-56-7B engines are fadec controlled and the eec provides for inflight flameout protection if there is an uncommanded reduction in N2 or N2 is below idle. The Fan is Wide chord but i'm not sure how much the core has changed? With regards to flight in heavy rain etc the manual says, avoid if possible but to place the start switches to "CONTinuous" probably as a backup to the auto relight function. No minimum N1 is specified, it does say to "Maintain an increased minimum thrust setting", An old training capt once told me min 40% on app for spool up reasons alone! Maybe the Lawyers got involved. Always easy when your not in the hot seat yourself. As you said it will all come out soon. Regards. Kimir.
The newer cfm-56-7B engines are fadec controlled and the eec provides for inflight flameout protection if there is an uncommanded reduction in N2 or N2 is below idle. The Fan is Wide chord but i'm not sure how much the core has changed? With regards to flight in heavy rain etc the manual says, avoid if possible but to place the start switches to "CONTinuous" probably as a backup to the auto relight function. No minimum N1 is specified, it does say to "Maintain an increased minimum thrust setting", An old training capt once told me min 40% on app for spool up reasons alone! Maybe the Lawyers got involved. Always easy when your not in the hot seat yourself. As you said it will all come out soon. Regards. Kimir.
Last edited by kimir; 20th Apr 2013 at 00:36.
An old training capt once told me min 40% on app for spool up reasons alone! Maybe the Lawers got involved.
In another life there was a company procedure designed by our chief pilot that we must never come below a certain approach power setting on final below 1000 ft. It was an an F28 and to do with the chief pilot's personal opinion on spool up times in case of a go-around.
While under line training I needed to reduce thrust a smidgin to adjust speed on short final although the glide slope was spot on. The checkie screamed at me that I was breaking company SOP by bring the throttles back below the magic spool up number introduced by the chief pilot.
I said no problem - in that case I am now going around. Don't go around for fukc sake screamed the checkie- just don't do it again..
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From personal experience Centaurus bringing the thrust back too idle on approach in gusty conditions can leave you in a low power, decreasing airspeed with slow engine acceleration (not as bad as earlier generation engines) situation. I still use 40% N1 as a ball park minimum on approach.... and yes this "technique" has worked for me for many years. 
What sort of Higher than minimum N1 do you think Vol 1 FCOM is referring to? What do you use? Not a dig just a question? All the best. Kimir
What sort of Higher than minimum N1 do you think Vol 1 FCOM is referring to? What do you use? Not a dig just a question? All the best. Kimir
Last edited by kimir; 20th Apr 2013 at 03:47.
The chaps posting that CRM is about empowering the f/o to speak up or about having a democratic meeting about where the flaps should be set etc are either the victims of terrible CRM training or they are out of touch with what CRM is.
There is no doubt that moving the flap to 15 at that stage ( if it occurred) is a technical error, I agree with that, but what caused it? Was it a communication error? A decision making error? Lack of S.A? Poorly managed flight resulting in overload late in the approach? Lack of authority gradient?
Technical errors normally follow a series of non technical errors, CRM is the non technical elements that place pressure on the tech skills if not done well.
Would the same flight have ended differently if different decisions had been made earlier in the flight? Yip. Well those decisions are CRM.
To think that a flights successful outcome is totally dependent on tech skills and independent of non tech skills ( CRM ) is not realistic.
Non tech skills (CRM) are just that.......skills. They can be taught and improved. In fact that is what the old school guys did, they taught themselves CRM or were taught it by more experienced pilots , they just didn't call it CRM.
I am in my early forties, not a child of the magenta line and lucky enough to have been taught by some of the old school guys, but also able to accept the change and view of the modern thinking in our industry, a nice position to be in as I can see the value in both mind sets.
Rubbishing CRM is indicative of resistance to change in my opinion.
There is no doubt that moving the flap to 15 at that stage ( if it occurred) is a technical error, I agree with that, but what caused it? Was it a communication error? A decision making error? Lack of S.A? Poorly managed flight resulting in overload late in the approach? Lack of authority gradient?
Technical errors normally follow a series of non technical errors, CRM is the non technical elements that place pressure on the tech skills if not done well.
Would the same flight have ended differently if different decisions had been made earlier in the flight? Yip. Well those decisions are CRM.
To think that a flights successful outcome is totally dependent on tech skills and independent of non tech skills ( CRM ) is not realistic.
Non tech skills (CRM) are just that.......skills. They can be taught and improved. In fact that is what the old school guys did, they taught themselves CRM or were taught it by more experienced pilots , they just didn't call it CRM.
I am in my early forties, not a child of the magenta line and lucky enough to have been taught by some of the old school guys, but also able to accept the change and view of the modern thinking in our industry, a nice position to be in as I can see the value in both mind sets.
Rubbishing CRM is indicative of resistance to change in my opinion.
For those interested in the CRM question, there is a good discussion on CRM on the Turkish B737 accident at Schiphol, with questions beginning about here.
CRM first, is just "good breeding", an old-fashioned term from the 50's which in western cultures generally means good manners, respect for others, courtesy without meek compliance or brash disregard, listening first then speaking, reserved judgment in the face of contrary information, clear expression of one's views while maintaining the dignity of the conversation and remembering what people say.
Believe it or not, that can be done in a cockpit and although it's just the beginning, common courtesies work.
It is when ego, narrowed-vision, sense of unquestioned authority, anger, distraction and frustration all interfere with common courtesy, that trouble can occur. In question such as these, settling the matter on the ground is the only course of action.
As I mentioned in that thread, the cockpit is NOT a democracy; legally, historically and practically there is only one decision-maker in the cockpit. CRM is a way of placing all information before the crew. Often a decision is mutual, but in cases of strong disagreement where agreement cannot be reached on a course of action with all knowledge 'on the floor', the captain alone is the decision-maker.
CRM is not politeness and, unless incapacitation or it is clear that the potential for an accident is extreme, it is does not authorize or legitimate taking over the aircraft. Exceptions are clear where there is risk of an accident: The Air Blue A321 accident at Islamabad and the Air India Express accident at Madras and the Garuda approach into Bali were clear circumstances in which it would have been appropriate for the F/O to have taken control.
The law is clear: the captain answers for the safety of life and property, period. Even if s/he wanted to, the captain cannot hand over command authority to anyone board unless incapacitated or absent. CRM is intended to elicit all views relevant to the circumstances at hand, (captain, should we be at this altitude this far out...?", etc.) offered by all crew members. Someone speaking up from the back seat about altitudes, speeds, rates-of-descent, distances, direction, fuel or times is heard first, then considered, then discussed, then acted upon, even if action is no-action.
Such a CRM "moment" can be a quick exchange lasting less than a few seconds, or 10 - 20 seconds long, or a protracted minute unless there's a serious and complicated emergency, (QF32...) in which case it's a very long and demanding exercise for all.
There is nothing "new age" or soft and "psychobabble-ish" about CRM. It requires toughness, training and discipline just like SOPs do.
PJ2
CRM first, is just "good breeding", an old-fashioned term from the 50's which in western cultures generally means good manners, respect for others, courtesy without meek compliance or brash disregard, listening first then speaking, reserved judgment in the face of contrary information, clear expression of one's views while maintaining the dignity of the conversation and remembering what people say.
Believe it or not, that can be done in a cockpit and although it's just the beginning, common courtesies work.
It is when ego, narrowed-vision, sense of unquestioned authority, anger, distraction and frustration all interfere with common courtesy, that trouble can occur. In question such as these, settling the matter on the ground is the only course of action.
As I mentioned in that thread, the cockpit is NOT a democracy; legally, historically and practically there is only one decision-maker in the cockpit. CRM is a way of placing all information before the crew. Often a decision is mutual, but in cases of strong disagreement where agreement cannot be reached on a course of action with all knowledge 'on the floor', the captain alone is the decision-maker.
CRM is not politeness and, unless incapacitation or it is clear that the potential for an accident is extreme, it is does not authorize or legitimate taking over the aircraft. Exceptions are clear where there is risk of an accident: The Air Blue A321 accident at Islamabad and the Air India Express accident at Madras and the Garuda approach into Bali were clear circumstances in which it would have been appropriate for the F/O to have taken control.
The law is clear: the captain answers for the safety of life and property, period. Even if s/he wanted to, the captain cannot hand over command authority to anyone board unless incapacitated or absent. CRM is intended to elicit all views relevant to the circumstances at hand, (captain, should we be at this altitude this far out...?", etc.) offered by all crew members. Someone speaking up from the back seat about altitudes, speeds, rates-of-descent, distances, direction, fuel or times is heard first, then considered, then discussed, then acted upon, even if action is no-action.
Such a CRM "moment" can be a quick exchange lasting less than a few seconds, or 10 - 20 seconds long, or a protracted minute unless there's a serious and complicated emergency, (QF32...) in which case it's a very long and demanding exercise for all.
There is nothing "new age" or soft and "psychobabble-ish" about CRM. It requires toughness, training and discipline just like SOPs do.
PJ2
Last edited by PJ2; 20th Apr 2013 at 03:18.
"Good Breeding" is another way of saying that the family/ school environment that someone grew up in taught them CRM principals. I know I learnt a lot of mine working on the farm with my Grandad in my first 15 years.
Although I agree with a lot of what you just posted PJ, I still think that you are only describing a very limited portion of what CRM actually is. It feels like you limit it to how crew members interact and place particular emphasis on where command lies. Where command lies should never be in doubt.
Probably 90% of CrM principals apply to single crew operations as much as they do to multi crew operations.
Anyway, enough of a hijack, can anyone come up with a good reason that this was not a repeat of the Turkish accident in Schphol? Radio Altimeter fails, thrust levers come back, crew didn't notice because hands weren't on the thrust levers, or they didn't notice as they were hot and levers were at idle already.
Although I agree with a lot of what you just posted PJ, I still think that you are only describing a very limited portion of what CRM actually is. It feels like you limit it to how crew members interact and place particular emphasis on where command lies. Where command lies should never be in doubt.
Probably 90% of CrM principals apply to single crew operations as much as they do to multi crew operations.
Anyway, enough of a hijack, can anyone come up with a good reason that this was not a repeat of the Turkish accident in Schphol? Radio Altimeter fails, thrust levers come back, crew didn't notice because hands weren't on the thrust levers, or they didn't notice as they were hot and levers were at idle already.
Go Around
How about:-
NPA - auto throttle not used. Go around attempted (for whatever reason) by pushing TOGA switch but no follow up on levers to ensure TOGA engages (forgetting that they were in Manual Thrust).
Pure speculation of course.
However it is true that Indonesian aviation is rotten to the core. Poorly trained pilots with little personal discipline or standards. I know, I've had to try to train some of them not so long ago, all with thousands of hours and unable to fly basic IF. Corrupt officials all the way to the top. EU foolishly allowed Garuda back into Europe saying that the Authority was now conducting proper supervision of all operators which we all know is laughable. This is the same Authority that allows Merpati to still hold an AOC even though they've had a fatal accident virtually every year for the past twenty or so years.
NPA - auto throttle not used. Go around attempted (for whatever reason) by pushing TOGA switch but no follow up on levers to ensure TOGA engages (forgetting that they were in Manual Thrust).
Pure speculation of course.
However it is true that Indonesian aviation is rotten to the core. Poorly trained pilots with little personal discipline or standards. I know, I've had to try to train some of them not so long ago, all with thousands of hours and unable to fly basic IF. Corrupt officials all the way to the top. EU foolishly allowed Garuda back into Europe saying that the Authority was now conducting proper supervision of all operators which we all know is laughable. This is the same Authority that allows Merpati to still hold an AOC even though they've had a fatal accident virtually every year for the past twenty or so years.
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The FDR & CVR have been out of the bay for almost a week now. By now, shouldn't some journalist have asked the NTSB team, led by Senior Air Safety Investigator Dennis Jones, or the Indonesian authorities, where they were sent for examination, and reported on when the work would be done?
Any of you journalists care to comment?
Any of you journalists care to comment?
Level Off at MDA
Yes you CAN level off at MDA legally and fly level to the MAP - dive and drive but this has been dropped by any self-respecting airline for years due to the number of accidents it produced.
A Constant Angle NPA - CANPA or CA APPROACH is flown like an ILS using (usually but not always) an increment of 50 ft added to the MDA so that one does not infringe the real MDA in a GA at MDA+50.
Much safer.
A Constant Angle NPA - CANPA or CA APPROACH is flown like an ILS using (usually but not always) an increment of 50 ft added to the MDA so that one does not infringe the real MDA in a GA at MDA+50.
Much safer.
framer;
Re, "I know I learnt a lot of mine working on the farm with my Grandad in my first 15 years."
Yep; that's what I meant. One learns it at another's knee, so to speak.
Re, "I still think that you are only describing a very limited portion of what CRM actually is."
Very likely - I'd welcome a discussion on that sometime as my experience is limited to airline ops.
Cheers!
PJ2
Re, "I know I learnt a lot of mine working on the farm with my Grandad in my first 15 years."
Yep; that's what I meant. One learns it at another's knee, so to speak.
Re, "I still think that you are only describing a very limited portion of what CRM actually is."
Very likely - I'd welcome a discussion on that sometime as my experience is limited to airline ops.
Cheers!
PJ2
Last edited by PJ2; 20th Apr 2013 at 06:10.