Russian B737 Crash at Kazan.
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Well, it looks as if my earlier post re the mechanics of the event was mostly on the money despite the flak it attracted...
But the "cause"?
This is a telling quote and I suspect will prove closer to the "cause" than anything else.
On the face of it a 2500 hr Capt is at the lowest end of the experience bracket even in one of the superbly trained W European airlines. Or he would be if he were a 25 yr-old wheel. But at 47? Strikes me that age and experience pairing is a bit out of kilter. Add a cojo in a similar bracket...
Capt with 2500hrs and Cat 1 rated only? Could be down to two things but neither option make me feel warm and fluffy. Either the company was too disorganised to get him Cat II rated - which bespeaks a less than well run training department or he wasn't thought up to it yet. I can't think of another reason. Neither fit comfortably with the crew experience level published. Either fit perfectly with what we know - or assume we know about Russian regionals.
Poorly run training depts don't fit with 2500hr Capt and 200FOs in their late 40s running a 737. Ditto 47yr old Capts who haven't been Cat II rated for any other reason.
And as this accident is almost certainly down to crew confused way before the LOC (captured g/s at 1000ft, 3 miles wasn't it???) and a completely botched g/a with all the hallmarks of total, terminal confusion and loss of spatial awareness and mishandling (I know, I've been there in the 737 sim on a g/a) by both pilots and we have to wonder if the age and experience gap didn't play a big part.
Try this on...
Career Navigators/Engineers out of An12s /72s re-streamed as pilots at age 42/43 as their coal-burners were retired. Some will hack it, but I think we can all see that without rigorous selection and training, and rigorous chopping too when appropriate you can't credit 10,000hrs on the systems panel of a freighter as any relevance to piloting a 737 size airliner. Does the word "rigorous" seem to apply in this context? Hmm. But if you do (and i'm guessing here, but how far wide of the mark is the guess - do you think?) you'll have a pilot demographic that is just asking for this sort of event.
But the "cause"?
the captain of the flight (47, ATPL, 2736 hours total, 2509 hours on type, 528 hours in command) was rated for CAT I ILS approaches only, the first officer (47, no type of pilot rating provided, 2093 hours total, 1943 hours on type) was rated for CAT II ILS approaches.
On the face of it a 2500 hr Capt is at the lowest end of the experience bracket even in one of the superbly trained W European airlines. Or he would be if he were a 25 yr-old wheel. But at 47? Strikes me that age and experience pairing is a bit out of kilter. Add a cojo in a similar bracket...
Capt with 2500hrs and Cat 1 rated only? Could be down to two things but neither option make me feel warm and fluffy. Either the company was too disorganised to get him Cat II rated - which bespeaks a less than well run training department or he wasn't thought up to it yet. I can't think of another reason. Neither fit comfortably with the crew experience level published. Either fit perfectly with what we know - or assume we know about Russian regionals.
Poorly run training depts don't fit with 2500hr Capt and 200FOs in their late 40s running a 737. Ditto 47yr old Capts who haven't been Cat II rated for any other reason.
And as this accident is almost certainly down to crew confused way before the LOC (captured g/s at 1000ft, 3 miles wasn't it???) and a completely botched g/a with all the hallmarks of total, terminal confusion and loss of spatial awareness and mishandling (I know, I've been there in the 737 sim on a g/a) by both pilots and we have to wonder if the age and experience gap didn't play a big part.
Try this on...
Career Navigators/Engineers out of An12s /72s re-streamed as pilots at age 42/43 as their coal-burners were retired. Some will hack it, but I think we can all see that without rigorous selection and training, and rigorous chopping too when appropriate you can't credit 10,000hrs on the systems panel of a freighter as any relevance to piloting a 737 size airliner. Does the word "rigorous" seem to apply in this context? Hmm. But if you do (and i'm guessing here, but how far wide of the mark is the guess - do you think?) you'll have a pilot demographic that is just asking for this sort of event.
Last edited by Agaricus bisporus; 29th Nov 2013 at 14:08. Reason: Deleted "Incoming! Head down!" I can stand up safely to this I think.
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Interesting article in English, describing situation of the airline:
Nose-Diving ‘Tatarstan’ - Investigations - Novaya Gazeta
For example:
Nose-Diving ‘Tatarstan’ - Investigations - Novaya Gazeta
For example:
...an average monthly salary of a trade union member is about 100,000 per month, while the pilot’s salaries are comparable to those in large airline companies.
It is because of the huge debts that the ‘Kazan airport stopped to fuel the ‘Tatarstan’ airline planes. That is why all airplanes flying, say, to Moscow, got fueled in the capital. As such, they filled the tanks in such a way that they would have enough fuel for the return flight as well. At the time of the plane crash on 17 November in the tanks of the ill-fated Boeing there was approximately nine tons of fuel
...shortly before the flight it became known, that two business class passengers had registered for the flight. And the 50-seater Bombardier CRJ was not equipped with the business class section. Having learned that the Tatarstan President’s son and the Head of the Tatarstan FSB Directorate were flying to Kazan, the ‘Tatarstan’ airline management urgently replaced Bombardier CRJ by Boeing.
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In addition to Karel's post here's another cut n' paste from his link.
They certainly didn't get 2000hrs flying between 2012 and the accident, so barring bad reporting where did they get their 2000hrs-odd flying time? On the systems panel...? Navigating?
This is like putting the scrub-nurse into the heart surgeons shoes on the basis she's seen a few score of bypass operations and "done a conversion"!
If this has been reported correctly it's a scary situation.
Due to a disastrous staff scarcity the enterprise would persuade air navigators and panel operators to retrain as pilots. That was how the crew members of the ill-fated ‘Boeing’ flying from Moscow to Kazan on 17 November got their permit to operate. Before 2012 the captain Rustam Salikhov was an air navigator, retrained in the Ulyanovsk Higher Civil Aeronautics School, and had transition training for ‘Boeing’ at the simulation center of the S7 airline. In 2012 he was appointed the second pilot and in May 2013 – the Captain.
The second pilot, Viktor Gutsul, prior to 2012 flew as panel operator.
Both, Rustam and Viktor, became pilots already after retirement, having obtained the service record flying as an air navigator and a panel operator. They were 47 years old.
In 2010 pilot rating was abolished. Previously, only A-class pilots with the flying time of at least 4,000 hours had the right to fly passengers. Both Salikhov and Gutsul’s flying time was about half of this norm. And it’s not their fault that they found themselves at the Boeing wheel on 17 November. It is their tragedy. And the passengers' tragedy
The second pilot, Viktor Gutsul, prior to 2012 flew as panel operator.
Both, Rustam and Viktor, became pilots already after retirement, having obtained the service record flying as an air navigator and a panel operator. They were 47 years old.
In 2010 pilot rating was abolished. Previously, only A-class pilots with the flying time of at least 4,000 hours had the right to fly passengers. Both Salikhov and Gutsul’s flying time was about half of this norm. And it’s not their fault that they found themselves at the Boeing wheel on 17 November. It is their tragedy. And the passengers' tragedy
This is like putting the scrub-nurse into the heart surgeons shoes on the basis she's seen a few score of bypass operations and "done a conversion"!
If this has been reported correctly it's a scary situation.
Last edited by Agaricus bisporus; 29th Nov 2013 at 14:05.
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Engines accelerated to 83% N1 (near Go-Around Thrust) and continued at that speed until almost impact.
There's been much speculation about over pitch-up due to the application of full G/A power. If they applied only 83% N1 this would have given only about 1500fpm V/S, if F15 speed was to maintained, and should have been easily controllable. It was also reported that they achieved 25 degrees nose up attitude. I suggest this must have been due to over controlling of elevator input. As the speed bled off the elevator would become less effective and thus it would have taken an equally large amount of over controlling elevator input to convert this high nose attitude into a steep dive. I wonder what the speed trim system was doing during all of this; i.e. where the stab trim was; helping or hindering during such large changes in attitude and elevator forces.
There's been much speculation about over pitch-up due to the application of full G/A power. If they applied only 83% N1 this would have given only about 1500fpm V/S, if F15 speed was to maintained, and should have been easily controllable. It was also reported that they achieved 25 degrees nose up attitude. I suggest this must have been due to over controlling of elevator input. As the speed bled off the elevator would become less effective and thus it would have taken an equally large amount of over controlling elevator input to convert this high nose attitude into a steep dive. I wonder what the speed trim system was doing during all of this; i.e. where the stab trim was; helping or hindering during such large changes in attitude and elevator forces.
DOVE
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Could it be that while one was pulling the control wheel (Go Around!) the other was trimming down, and even pushing? (I see the runway I can make it!)
Is it difficult to determine this?
Is it difficult to determine this?
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Unlikely as it was the captain that informed ATC they were making a go-round. Because of that it was not a panicked manoeuvre at minimums; it seems to have been a discussed option and the F/O PF would have known what was the idea.
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Advising ATC
quote
It is also advising that air traffic control processes be examined to explore whether controllers could provide greater assistance to crews in cases where aircraft are deviating significantly from the required course.Unquote
Any suggestions so far.
It is also advising that air traffic control processes be examined to explore whether controllers could provide greater assistance to crews in cases where aircraft are deviating significantly from the required course.Unquote
Any suggestions so far.
They performed a go around ending in a steep climb, pushed over to level off......
Then comes the deadly part, the ever increasing negative pitch until impact.
Something floating around when doing the pushover jammed the controls?
Then comes the deadly part, the ever increasing negative pitch until impact.
Something floating around when doing the pushover jammed the controls?
Originally Posted by Gobonastick
Why do people these days think that official information only exists if it's on a web link...?
Originally Posted by The Aviation Herald
After passing the missed approach point the crew discussed a go-around and communicated with dispatch, then disengaged both autopilots engaged in the automatic approach and continued manually on flight director.
Originally Posted by MAK
Оценив положение самолёта относительно ВПП как «непосадочное», экипаж доложил диспетчеру и начал уход на второй круг в режиме TOGA (Take Off / Go Around. Взлёт / Уход на второй круг). При этом, задействованный в процессе захода на посадку один из двух автопилотов, был отключён и дальнейший полёт осуществлялся в ручном режиме.
Originally Posted by The Aviation Herald
the stabilizer trim system wound - most likely automatically - nose down commanding the aircraft into a dive.
Originally Posted by David Kaminski-Morrow
The engines were powered up to 83% of N1 and, aided by flap and gear retraction, the aircraft climbed at 25°. Airspeed bled away and the 737’s speed trim system – which acts to stabilise the airspeed in such situations – began adjusting to favour a lower nose attitude.
Originally Posted by F14
looks like a Go-Around without pressing TOGA. Followed the FD's into the ground
Originally Posted by RAT5
It was also reported that they achieved 25 degrees nose up attitude. I suggest this must have been due to over controlling of elevator input.
Originally Posted by RAT5
I wonder what the speed trim system was doing during all of this
Originally Posted by DOVES
Could it be that while one was pulling the control wheel (Go Around!) the other was trimming down, and even pushing?
Originally Posted by DOVES
Is it difficult to determine this?
Originally Posted by veloo maniam
Any suggestions so far.
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Dual inputs are impossible on the 737 unless so much force is applied that the breakout feature (for jammed controls) is used. As for one pilot trimming in the wrong direction, this can only be done manually - the electric trim is available in the needed direction only (a force direction switch in the base of the column isolates the opposite trim direction unless the override switch on the aft edge of the centre pedestal is used), ad manual rotation of the trim wheel would produce a very slow trim change and is unlikely to go un-noticed. So, the chances of opposing pilot actions are small.
DOVE
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To Clandestino
And what about this?:
#299 (permalink)
To Olasek
It only means that average vertical speed was 70 kts, it says nothing about their final speed at the time of the crash.
Can I ask you humbly:
"If average was 70 kts, what has been minimum?"
Quote:
According to FDR, no.
Originally Posted by DOVES
Could it be that while one was pulling the control wheel (Go Around!) the other was trimming down, and even pushing?
Could it be that while one was pulling the control wheel (Go Around!) the other was trimming down, and even pushing?
#299 (permalink)
from avherald:
... After passing the missed approach point the crew discussed a go-around and communicated with dispatch, then disengaged both autopilots engaged in the automatic approach and continued manually on flight director. Engines accelerated to 83% N1 (near Go-Around Thrust) and continued at that speed until almost impact. The aircraft began to pitch up under the influence of engine acceleration and flaps retraction reaching 25 degrees nose up, ["the stabilizer trim system wound"] - most likely automatically - nose down commanding the aircraft into a dive. ...
... After passing the missed approach point the crew discussed a go-around and communicated with dispatch, then disengaged both autopilots engaged in the automatic approach and continued manually on flight director. Engines accelerated to 83% N1 (near Go-Around Thrust) and continued at that speed until almost impact. The aircraft began to pitch up under the influence of engine acceleration and flaps retraction reaching 25 degrees nose up, ["the stabilizer trim system wound"] - most likely automatically - nose down commanding the aircraft into a dive. ...
Quote:From 700 m (2310 ft) to zero in 20 secs, means 6930 ft/min??? It means 126 Km/h and 70 Kts
"If average was 70 kts, what has been minimum?"
Last edited by DOVES; 30th Nov 2013 at 21:27.
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IMHO 83% N1 is not enough (in the sim) to put the a/c any where near 25 degrees nose up even if you did not touch the elevator. IMHO this hi-attitude must have been pilot induced. Considering this hi-nose attitude at such a low power setting the speed bleed off must have been rapid. I'm surprised they didn't get a stick shaker. If they did this might explain the over control into nose down, but surely it would have been reported. Indeed the STS would have wound in nose down trim, but how quickly, and then if a large nose down elevator input was made the STS might not have had time to wind off that nose down trim. However, the elevator must have been like a wet fish at such a slow speed, hence perhaps such a large reverse input. Does the FDR not show elevator input in degrees against time?
Too much of a coincidence in my view. The cloud base was low, and the go-around was at night, so I'll bet the crew could see a whole load of dark grey nothing in front of them
Such a G/A manoeuvre is an instrument manoeuvre even in day light. Above 10 degrees you can not see over the nose. Good instrument discipline should not have led to this outcome. A G/A as a takeoff is to rotate to an attitude. that is fundamental and should be the focus. PM should have ensured correct thrust was set and monitored the attitude, especially as PM was the captain who instructed the G/A.
My interest is in the root cause of the accident. that started way back when they did not intercept the ILS correctly. How can it be that a B737 with all the MAP nav displays and LNAV/HDG SEL/ TK LIne be so far off course that they are not on the ILS at night when inside the OM? That is where the accident began. How? How can 2 trained pilots be so lost in S.A? What happened afterwards was as a consequence of being out of position. Good decision, but badly executed. Why was it necessary is my question. Therein lies some clues and perhaps identifying a weakness in the ATC, crew training, STAR procedure etc. There has to be more to this than a messy G/A.
Too much of a coincidence in my view. The cloud base was low, and the go-around was at night, so I'll bet the crew could see a whole load of dark grey nothing in front of them
Such a G/A manoeuvre is an instrument manoeuvre even in day light. Above 10 degrees you can not see over the nose. Good instrument discipline should not have led to this outcome. A G/A as a takeoff is to rotate to an attitude. that is fundamental and should be the focus. PM should have ensured correct thrust was set and monitored the attitude, especially as PM was the captain who instructed the G/A.
My interest is in the root cause of the accident. that started way back when they did not intercept the ILS correctly. How can it be that a B737 with all the MAP nav displays and LNAV/HDG SEL/ TK LIne be so far off course that they are not on the ILS at night when inside the OM? That is where the accident began. How? How can 2 trained pilots be so lost in S.A? What happened afterwards was as a consequence of being out of position. Good decision, but badly executed. Why was it necessary is my question. Therein lies some clues and perhaps identifying a weakness in the ATC, crew training, STAR procedure etc. There has to be more to this than a messy G/A.
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This is the original source used by flightglobal and avherald (in Russian):
http://www.privmtu.ru/safety_flights/info/pd_VQ-BBN.pdf
Avherald has the important parts translated pretty much word for word. The only detail that may have been mistranslated is the description of pilots' actions. The original source says that "when the speed dropped from 150 kt to 125 kt with pitch angle of 25 degrees, pilots started actions with the control column in order to reduce pitch. (...) EGPWS alerts "sink rate" and "pull up" sounded, but there were no significant nose-up inputs on the control column, and vertical acceleration became negative". In essence, avherald makes it sound as if one of the pilots held the column full forward all the way into the ground, but that does not necessarily follow from the original text.
One other interesting part is that it sounds like they failed to acquire the glide slope because they were 300 m above ground at 2 km before the runway, and that was because they had the auto pilot set to hold altitude.
http://www.privmtu.ru/safety_flights/info/pd_VQ-BBN.pdf
Avherald has the important parts translated pretty much word for word. The only detail that may have been mistranslated is the description of pilots' actions. The original source says that "when the speed dropped from 150 kt to 125 kt with pitch angle of 25 degrees, pilots started actions with the control column in order to reduce pitch. (...) EGPWS alerts "sink rate" and "pull up" sounded, but there were no significant nose-up inputs on the control column, and vertical acceleration became negative". In essence, avherald makes it sound as if one of the pilots held the column full forward all the way into the ground, but that does not necessarily follow from the original text.
One other interesting part is that it sounds like they failed to acquire the glide slope because they were 300 m above ground at 2 km before the runway, and that was because they had the auto pilot set to hold altitude.
Dozy:
Thank you.
Clandestino:
Thanks for your point on MAK, with whom I am not familiar, and no thanks for the rest of your usual.
Thank you.
Clandestino:
Thanks for your point on MAK, with whom I am not familiar, and no thanks for the rest of your usual.
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- After starting G/A, while they climb (ca 20 sec), they communicate with TWR for 16 sec. Could it distract their attention?
- Clouds ceiling was actually 220m, that means that they could see airport lights only for the last 2 sec of flight.
- In the moment of t/o, they had 7.8 tons of fuel, i.e. the information about 9 tons of fuel in the moment of crash is incorrect.
- Clouds ceiling was actually 220m, that means that they could see airport lights only for the last 2 sec of flight.
- In the moment of t/o, they had 7.8 tons of fuel, i.e. the information about 9 tons of fuel in the moment of crash is incorrect.
Originally Posted by DOVES
And what about this?:
Originally Posted by RAT5
IMHO 83% N1 is not enough (in the sim) to put the a/c any where near 25 degrees nose up even if you did not touch the elevator.
Originally Posted by RAT5
IMHO this hi-attitude must have been pilot induced.
Originally Posted by RAT5
Considering this hi-nose attitude at such a low power setting the speed bleed off must have been rapid.
Originally Posted by RAT5
I'm surprised they didn't get a stick shaker.
Originally Posted by RAT5
Does the FDR not show elevator input in degrees against time?
Originally Posted by hamster3null
In essence, avherald makes it sound as if one of the pilots held the column full forward all the way into the ground, but that does not necessarily follow from the original text.
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The apparent passivity of the crew on the controls is making this sound like another case of a crew that was too automation dependent and when forced to fly manually, they were unable to get their scans going and actually fly the aircraft.
I've been expecting more horrible examples of inadequately trained crews, but it is a great disappointment when they actually show up.
I've been expecting more horrible examples of inadequately trained crews, but it is a great disappointment when they actually show up.
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It could have captured a false glide slope or suffered some sort of disturbance to the glide - I have seen that in a few places where local geology, topography or conurbations, or having a taxiway with lining-up aircraft in front of the G/S transmitter causes significant G/S distortion.
As for how a crew could end up in the wrong position for intercept, just last night I had bad vectors from ATC to the ILS, and look at the Atlas thread where they went for the wrong airport entirely. Anyone can have an abberation - what's important is understanding why and learning what can be done to mitigate them.
As for how a crew could end up in the wrong position for intercept, just last night I had bad vectors from ATC to the ILS, and look at the Atlas thread where they went for the wrong airport entirely. Anyone can have an abberation - what's important is understanding why and learning what can be done to mitigate them.