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Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain

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Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain

Old 27th Mar 2014, 13:49
  #21 (permalink)  
 
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This is stupid

We had defined terminology too: "first name; i dont feel comfortable with this approach, do you think we should go around"
-followed by-
"This is Stupid"
The idea of raising the gear in what's already an unstable approach is, er interesting, but that brings all a host of other problems too; especially if the PF is fixated or saturated. TOGA is perhaps a better idea..
I fly by the simple missive; if there is ANY doubt, then there is NO doubt..
~blue skies. Horrible accident.
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Old 27th Mar 2014, 14:17
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Educating me

Clunkdriver, thanks for starting to educate me re: task saturation. How easy is it to create this in the sim, and are there any signs of it that identiy it well enough that in and of themselves could be a sign to go around. My apologies for use of the bonehead term. I know this poor guy didn't want to crash.
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Old 27th Mar 2014, 23:32
  #23 (permalink)  
 
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TOGA is perhaps a better idea..

TOGA will certainly be an effective method of forcing a GA. But the strong pitch up caused by GA thrust would certainly catch the offending captain completely by surprise. Especially in IMC he may not have a clue what the co-pilot is up to and by the time he twigs to what's happening allow the aircraft to reach an alarmingly high body angles which could lead to a stall which is not what the co-pilot had in mind!! TOGA can be dangerous if unexpected...
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Old 28th Mar 2014, 10:57
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But the PNF who pressed TOGA is expecting it and can help an overloaded PF by taking control or applying pressure or trim.

It's more a psychological issue of having FOs trusting Captains and believing that their vocal inputs will get them back in the groove. I've been there - I had two events where in hindsight the Captain was more incapacitated or confused than I had perceived and taking control would have been the better course of action rather than continued vocal intervention. I think it's something that really could be helped by training in the sim, where the Captain is told quietly by the TRI to start making mistakes and misjudgements but the FO isn't made aware of the scenario, a bit like when the typical RTO with incapacitated pilot is done, but much subtler. The idea is to show that mild incapacitation might allow the PF to give all the SOP responses but to make poor decisions and fail to react to other indications and that the FO has to make a decision to take control even though the other guy appears concious. Incapacitation training seems to be far to obvious at the moment, with the incapacitations always being total.
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Old 28th Mar 2014, 17:47
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This report is a good example of how human factors can be considered by investigators; however it is disappointing that all of this effort could not be followed through with recommendations. This is not to criticise the report, but more to recognise the difficulties of applying suppositions of HF and the limitations of international reporting formats.
Thus it is up to organisations and individuals to form their own conclusions and consider areas of safety activity.

Regulators and operators must consider the increasing reliance on human intervention for the growing complexity of the operating environment. This aircraft like many others had system updates and additions with little opportunity for integration, thus different AP / FD operation, mode annunciations, GPS inputs, etc had to be managed with increasing workload. Often each change is seen in isolation – ‘the crew will manage with training’, yet the cumulative effects could be significant. Thus the conjunction of these factors together with a ‘tight’ approach and compass problem exceeded the crew’s mental resources with unfortunate results.
Who will say ‘No’ to these situations? The crew as the last line of defence, yet most likely to be affected by the workload? No, these issues must be addressed at the organisational level, where time and resources are available to balance the competing pressures.

Those who see CRM, assertiveness, or monitoring pilot intervention as solutions perhaps overlook the effect of hindsight bias. Why should a monitoring pilot have the better understanding of the situation; the more experienced pilot might have, but if the monitoring pilot’s perception is incorrect then any intervention could be hazardous.
In this accident each pilot appears to have had a different understanding of the situation, and at that time there was no quick means of establishing which was correct. With hindsight, and assuming that the difference in awareness was recognised, discontinuing the approach and reassessing is a solution may have helped, but with problems of high workload, human bias, and limiting mental resources then these defences (CRM) cannot be expected to work. See the BEA ASAGA study – ‘the concept of CRM is flawed’.

Solutions to these types of accident resided at much higher levels of organisation and regulation than with the crew. If the accumulative effects of system ‘enhancements’ are recognised, then either operational or technical restrictions should be applied, or mandate additional safety defences – EGPWS, before operational approval is given.
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Old 28th Mar 2014, 18:26
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Very true. It is sometimes very ard for someone who has become disorientated or gone down a wrong mental avenue to recognise it, and so is difficult for them to agree with a PNF telling them a contradicting tale...
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Old 28th Mar 2014, 18:34
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The final factor which doomed this flight was an EXPERIENCED non -asertive F/O,
A trawl through any accident database will demonstrate that on the day experience counts for very little. There are just as many memorials to experienced crews as there are to inexperienced crews. The goal is to always be effective as crew, that way you may also live to be experienced.
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Old 28th Mar 2014, 20:58
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According to the report the FO had just over 100 hours on the 737, so was recently line released. He was previously a turboprop captain and does not seem to have had any other jet experience. He gets paired up with a guy who should know what he is doing. The captain mishandles the approach and the FO who is obviously well behind the aircraft knows something is wrong but clearly cannot quite believe what is happening. I would not say that the FO was particularly experienced in this case at least on a relevant aircraft. In any case it is a sobering report. As they say better one go-around too many rather than one too few.
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Old 28th Mar 2014, 22:30
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lederhosen, IMHO you overlook the key issue. If the crew, individually or jointly, have reach the limit of their mental capacity in attempting to understand the situation, then there is no further mental resource either to intervene with a warning, or achieve and execute a decision to go around.
These situations represent a boundary of human capability in aiding safety, thus interventions must be found elsewhere.

Experience is just one of many contributing factors in human behaviour, but as we have difficulty in defining and teaching experience, and fewer opportunities of ‘being there’, these circumstances should be of some concern particularly with the apparent reducing emphasis on training and skill level.
The industry has to reconsider the operating environment in which the human is expected to manage and the demands being made on human mental resource, both in knowledge and skill, as well as how close modern complex operations are to an acceptable safety boundary.
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Old 29th Mar 2014, 02:25
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Hindsight bias

There is a lot of hindsight bias going on in this thread. It's easy to talk about what the FO could have done or might have done and the assume that everything works perfectly from there on out--maybe it does and maybe it doesn't. Maybe the aircraft gets into a situation where the FO is doing one thing and the Captain is doing another and it winds up in the dirt anyway.

What caught my eye is this:
1641:16.3 Captain makes statement indicating similar situation happened to another pilot previously
So thirty seconds before the crash the Captain is in a mental place where he has got it all figured out. He's seen this before. And he is following this cognitive map in his head despite the fact that the FO officer is telling him the map is wrong.

So let me play the troublemaker a little bit.

1639:13 to1639:30 FO makes 5 statements regarding aircraft lateral displacement from desired track.
I wonder how much the FO nagging added to the Captain's task saturation. Perhaps at some point in time the Captain simply started to tune him out. The Captain is may be thinking, "I've got it all figured out. Why the hell is he bugging me?" Maybe if the FO had just shut up the pressure would have been off and the Captian would have figured it out on his own.

There is more than one way to engage in hindsight.

Last edited by MountainBear; 29th Mar 2014 at 02:28. Reason: formatting
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Old 29th Mar 2014, 02:39
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But the PNF who pressed TOGA is expecting it and can help an overloaded PF by taking control or applying pressure or trim.

I would have thought the last thing you want is having both pilots putting inputs into the controls at the same time and possibly in opposition. Recipe for confusion and disaster.


If the PNF is actuating the stab trim without the PF being aware of it, it is possible the PF may think he has a runaway (uncommanded) stab trim movement and act as per QRH Runaway Stabilizer which is Control column...Hold firmly. Stab Trim Cutout switches....Cutout.


Meanwhile the nose is rearing up under full thrust. The mind boggles at the scenario
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Old 29th Mar 2014, 04:12
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A few decades ago, I was right seat in a Viscount simulator when PF managed to get inverted (with the help of a white on black WWII vintage AH) at 16,000'.

I spent the next minute or so shouting in his ear that:
  1. We're upside down!
  2. Roll it back up!

His auditory channel had very firmly shut down

I had a little talk with myself about how hard it is to take over -- and that if I want to walk away from a similar situation in a real a/c, I'll have to take over in time to recover.

There's major psychosocial barriers to the FO taking over.

I second the suggestion that the simulator is a good place for PF to set up a situation where PM has to intervene.
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Old 29th Mar 2014, 07:53
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In some people's eyes, a go-around in the circumstances described in the 737 accident, is seen as an admission of mistake and a "it can't happen to me" mindset takes over momentarily. The wavering of the first officer is understandable as he contemplates the awful realisation the captain is wrong and yet the F/O is reluctant to shove open the power and haul back on the stick since he knows the consequences for his job if indeed the captain was right. I doubt all the SOP or education in the world can cover the situation that any first officer finds himself under similar circumstances.

It might even boil down to one's personal physical courage. I believe that to be the case here. An F/O is seen as making serious waves if he forcibly takes over the controls at any time. Ethnic culture also plays a large part in this sort of lack of decision making as we have frequently seen in accidents such as the Asiana B777 crash at SFO. Not that appeared to be a problem in the 737 accident.

As an avid reader of accident reports, instilled in me from my early years as a military pilot - and where these reports were always readily available in military crew rooms, I believe each operator's flight safety manager should ensure that both overseas and local (own country) accident and incident reports should be readily available to crews. It is all very well having to regurgitate endless published bumpf on CRM and TEM or whatever is the next fancy name. But studying the cold hard facts in an accident report should never be boring and will generally be remembered.


What should interest a professional pilot is why a pilot made or failed to make a critical decision and the deadly result. An accident report tells you that. It should not be left to individual pilots to research for themselves because few will, in my experience. They have too many other activities to concern them - unless they live for flying (and devour Pprune accident reports!)

"There but for the Grace of God go I" reading of accident reports is a powerful educational tool. Those of us who have followed this particular thread will have already learned a valuable lesson IMHO and hopefully apply it when they go flying next time. Forgive the somewhat inarticulate rambling on a tricky subject...

Last edited by Tee Emm; 29th Mar 2014 at 11:24.
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Old 29th Mar 2014, 08:38
  #34 (permalink)  
 
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PEI_3721 it is blindingly obvious that the crew got beyond their limits. Various posters including the one before my original post made reference to the co-pilot being experienced and like you seem to suggest it is not a relevant factor. Fact is that the first officer had very little time on type. It is also a fact that they crashed. A lot of other things being said are assertion.

I have been flying the 737 for many years with increasingly inexperienced co-pilots due to the way our industry is changing. I make plenty of mistakes like most people so I have a keen interest that crew resource management works. Airline management also would like to think that experience is not a safety issue. I do not agree.

In this specific case the mental overload occurred at least partly because the crew jointly allowed the aircraft to get well above path and rushed the approach. There seems to have been considerable confusion in the nav set up and approach briefing. The sops for callouts and other relevant items were not complied with. Surely more support from the pilot non flying would have reduced the workload on the captain and avoided his becoming task saturated?

Last edited by lederhosen; 29th Mar 2014 at 09:12.
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Old 29th Mar 2014, 11:01
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Surely more support from the pilot non flying would have reduced the workload on the captain and avoided his becoming task saturated?

More "support" from the PNF can be interpreted two ways. From the PF point of view or the PNF point of view. Too much"supporting" is often seen by the PF as irritating, superfluous and worse still, distracting. It all depends on from whose viewpoint.


We have all seen the situation where the PNF thinks he is doing what he thinks is the right thing and offering ideas, and advice but which drives the other pilot nuts dealing with the stream of words of encouragement - some of which is out of pure nervousness and even arse covering for the sake of the CVR and Big Brother..


In reality, the PNF is only verbalising what his own mind is thinking - all of which is not genuine SOP support but a chatter. In turn, this becomes counter productive as the PF is forced to acknowledge each transmission or comment or risk the PNF thinking "the bastard is incapacitated or in the "Red Zone" and needs more help and so the babbling continues.


There is something to be said for the old days before CRM was invented as a cottage industry. Then the PNF closely monitored an approach and silence was golden allowing the PF to concentrate on flying. Only if something was out of the ordinary would the PNF assess the flight path progress or whatever concerned him, and then would make a succinct comment which nowadays would be called a "support" call.
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Old 29th Mar 2014, 20:49
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TeeEmm, I have probably got the wrong end of the stick, but it sounds to me like you are stating the main CRM element comes down to how advocational/confident the PNF is. As my posts say, it's not down to character strength, confidence, fear of the Captain or company reaction that is the often the problem, and the standard accident response to that effect is part of the issue. It's more down to the PNF not realising just how mind-f***ed the PF is. Hindsight is a wonderful thing, and that is how we learn. PNFs must learn that unless they see corrective action promptly, they need to assume the overload or incapacitation of the PF is more extreme and they need to take physical control of the aircraft. It is not an unwillingness to speak up, as these transcripts clearly demonstrate, it's the lack of understanding by the PNF of how disorientated the PF is.

I have a very open, relaxed culture on my aircraft - I'm horrified at the company recommendation above that the Captain's first name be used in these circumstances - I expect all of my crew, even the newest cabin crew, to call me by name all the time, and my FOs are relaxed enough to banter and take the pee out of me as I do them during the non-critical times of the day (this has been the norm at all the companies where I have worked, with only a few Cpts being stern, pompous and moody). Even so, I have made mistakes where the FO should have commented but failed to do so because they thought I had some other cunning plan, despite deviating from the brief, and that's been with green and experienced FOs alike - it wasn't fear of my reaction but their over confidence in me that was at fault.

Because things normally run smoothly, I don't think many FOs realise how quickly things can go catastrophically wrong. That's why I think practicing more insidious incapacitations without warning or briefing in the sim may be useful, just like practicing missed approaches from below minimums with surprises like runway incursions and wind shear to eliminate the "we're through minimums, so we're in" mentality.
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Old 30th Mar 2014, 01:27
  #37 (permalink)  
 
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Lots of talk about the FO on here. The fact that he lacked assertiveness hardly mitigates the fact that the Captain, in spite of repeated calls from the FO, continued a unstable approach in IMC in hilly terrain with full deflection on the LLZ. Short of hitting TOGA and taking control (and if they subsequently never saw the ground losing his career), I don't see what else he reasonably could have done to save the aircraft from the PICs decisions
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Old 30th Mar 2014, 01:44
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Disagreement

Why can't the fact that there is a disagreement between the Captain and the FO, IN AND OF ITSELF, be a requirement to go around when it occurs during an approach? That seems to me a simple solution. How often do such events occur?
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Old 30th Mar 2014, 02:00
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Petercwelch's suggestion is a simple and brilliant one. Perhaps the PF should be trained to go around if he or she hears the words "Disagreement, go around" from the FO. No need to explain the cause of the disagreement, just have the word as a 911/999 emergency call?
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Old 30th Mar 2014, 03:01
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Why can't the fact that there is a disagreement between the Captain and the FO, IN AND OF ITSELF, be a requirement to go around when it occurs during an approach? That seems to me a simple solution. How often do such events occur?
This is the type of proposal that strikes me as "trying to solve the last accident". I am skeptical that it would do much good for two reasons. First, it might just transfer the indecision of a FO from one dilemma to another dilemma viz. from does he take control to how much disagreement is enough disagreement to call for a go around. Second, if the mere existence of any level of disagreement is enough to cause a go around then the number of go arounds will go through the roof. While a go around in an isolated location such as the one in this accident is no big deal a large increase in go arounds in congested airspace like NYC might cause far more problems that it solves.

One should avoid the temptation to solve the last accident. In this case the PNF was correct and the PF was incorrect. But how many times have the PNF been wrong and the plane landed without incident?
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