Thomas cook b757 incident, what a total mess
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bit of a Horlicks TBH - they got behind the 'plane, panic set in, and never really caught up
given that they had plenty of fuel for NCL and nothing was visibly going badly wrong they should have asked for a stack somewhere and spent a few minutes calming down, checking what was connected and what wasn't and reconfiguring the aircraft
given that they had plenty of fuel for NCL and nothing was visibly going badly wrong they should have asked for a stack somewhere and spent a few minutes calming down, checking what was connected and what wasn't and reconfiguring the aircraft
I sympathise with the crew and blame the operator. They were almost certainly trained from the very first simulator type rating session to use the automatics right from the start - instead of first being taught how to fly the aeroplane with their hands and feet. A classic example of todays training which accents the full use of automatics regardless if it is appropriate for the circumstances. Do you really need an automatic pilot to do a visual go-around? Of course not. I was amazed that the company even tells its crews to use mnemonics to remind them what they must consider. I thought mnemonics were only used by student pilots in the initial training. But for airline pilots? WTF
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Small comment from the observer gallery; I would rather be a passenger in an aircraft that has a severe bird strike in the last few feet of an approach, or after touchdown, than be a passenger in an aircraft that has a severe bird strike in the first stages of a go-around.
So if ATC or a crew reports a runway bird strike on the landing aircraft in front of the one I'm in, next week, I hope the PF continues the landing while being alert to the possibility of a bird strike and loss of power.
So if ATC or a crew reports a runway bird strike on the landing aircraft in front of the one I'm in, next week, I hope the PF continues the landing while being alert to the possibility of a bird strike and loss of power.
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Back to the ATCO possible ways of dealing with this situation, a few weeks ago we had a birdstrike (to the fuselage) crossing the threshold for landing. I reported it ASAP and tower asked the next plane if they had copied the info and if they where happy to continue, which they did. AFTER this plane landed all others were vectored for the other RWY as the one we (and the plane following) had used was closed.
I feel giving the option to the crew is better than suddenly instructing a go around (if not REALLY required). The crew might still elect to go around but would have some time to prepare. A few seconds is more than enough to highly improve the chances of the Go Around being flown as they are supposed to be flown. IMHO.
I feel giving the option to the crew is better than suddenly instructing a go around (if not REALLY required). The crew might still elect to go around but would have some time to prepare. A few seconds is more than enough to highly improve the chances of the Go Around being flown as they are supposed to be flown. IMHO.
Plastic PPRuNer
Have to agree with Capot.
Nevertheless, after many years of PPRuNe-ing it seems that a major review of the automatics/pilot interface is long overdue, as well as recurrent training in manual flight and abnormal situations.
I've seen this sort of Horlicks in modern operating theatres and the results can be scary - thereas out in the bush, in primitive theatres, everyone is tuned to manual and knows what to do.
Nevertheless, after many years of PPRuNe-ing it seems that a major review of the automatics/pilot interface is long overdue, as well as recurrent training in manual flight and abnormal situations.
I've seen this sort of Horlicks in modern operating theatres and the results can be scary - thereas out in the bush, in primitive theatres, everyone is tuned to manual and knows what to do.
I remember that when I was a Type/ Instrument Rating Examiner on the B757/767 (I'm retired now) the 2-engine go-around was frequently performed untidily in the sim, so much so that I included this procedure in my 'How To Do Well In The Sim' paper. It's disappointing to learn that crews are still getting themselves into trouble flying this manoeuvre.
I think a lot of this is sheer lack of practice. How often do pilots do an all engines Go Around (either on line or in the Sim)?
In this situation given the all engines performance, the low relative level off altitudes are a potential threat and IMHO should be briefed for.
That's why there are two pilots in the cockpit, both of whom should be adequately qualified, experienced and not fatigued.
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Here we have direction from the airport company that for a "possible" bird strike we will advise landing aircraft and continue operations until the runway can be inspected unless a pilot reports seeing something on the runway.
For a "confirmed" bird strike the surface is closed and must be inspected. No discretion.
Controllers and pilots should be allowed to use their discretion regarding bird strikes and other wildlife. Last night we received a phone call from the fire service watch room reporting a deer very close to the landing runway. A deer is much bigger than a bird so we suspended operations on that runway immediately. Only one aircraft missed the approach, all others were re-positioned to the parallel departure runway.
For a "confirmed" bird strike the surface is closed and must be inspected. No discretion.
Controllers and pilots should be allowed to use their discretion regarding bird strikes and other wildlife. Last night we received a phone call from the fire service watch room reporting a deer very close to the landing runway. A deer is much bigger than a bird so we suspended operations on that runway immediately. Only one aircraft missed the approach, all others were re-positioned to the parallel departure runway.
Below the Glidepath - not correcting
I was amazed that the company even tells its crews to use mnemonics to remind them what they must consider. I thought mnemonics were only used by student pilots in the initial training. But for airline pilots? WTF
The mnemonic in this case is intended to assist in regaining full situational awareness by highlighting the principle considerations. The time when you will forget or omit a critical factor is exactly when the workload has rapidly increased and the hairs on the back of your neck are standing up. To associate mnemonics with something done only by students during training is a fascinating concept in itself.
But taking over in this situation requires a lot of advocacy.
The duty started at 0500 for this crew. NCL to FUE and return is a long day, especially after a start this early. It's unlikely their mental faculties were functioning at max efficiency during the approach to NCL.
There is a significant problem with fatigue - how can a pilot blame fatigue if he is involved in an incident? The legal bods will say - you've broken the law by flying when fatigued. So what will pilots say? 'I was not suffering from fatigue as far as I was aware.' What else could a pilot say without being accused of breaking the rules?
Another consequence of fatigue is that it impairs judgement. This means that a person suffering from fatigue might not even realise it. They may not realise that they are not in a fit state to do aircrew duties.
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At least they have "level 6" english I beleive... what is everything in aviation now. And the briefing has been done for both runways and all kinds of approaches. Just TOGA has been forgotten to be depressed. Well done!
757 is easiest for GoAround- after pressing TOGA it slowly climbs with 2000 ft/min only - piece of cake!
757 is easiest for GoAround- after pressing TOGA it slowly climbs with 2000 ft/min only - piece of cake!
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I think a lot of this is sheer lack of practice. How often do pilots do an all engines Go Around (either on line or in the Sim)?
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The mnemonic in this case is intended to assist in regaining full situational awareness by highlighting the principle considerations. The time when you will forget or omit a critical factor is exactly when the workload has rapidly increased and the hairs on the back of your neck are standing up.
And due to this 'hairy neck syndrome' you forget the mnemonic. Then what? If you need these things as a crutch the perhaps you don't understand the basics and need more awareness.
Regarding the horlicks of simple 2 engine manual G/A's. I was B757/767/737 TRI/TRE in various companies. It was common complaint/observation that this manoeuvre was performed unsatisfactorily. How dis they know? Because it was when it happened on the line. When was it trained/checked? Never, after the first initial TQ course. The prof check is a slow single engine G/A and the LVO is an auto G/A. Push the button and let George do his thing. Solution; more recurrency training of a known weakness. Resulting answer; nothing extra at all. Sad day for training departments. No crashes on G?a so no further training required. Incidents? Many, but all survived. Sad days indeed.
And due to this 'hairy neck syndrome' you forget the mnemonic. Then what? If you need these things as a crutch the perhaps you don't understand the basics and need more awareness.
Regarding the horlicks of simple 2 engine manual G/A's. I was B757/767/737 TRI/TRE in various companies. It was common complaint/observation that this manoeuvre was performed unsatisfactorily. How dis they know? Because it was when it happened on the line. When was it trained/checked? Never, after the first initial TQ course. The prof check is a slow single engine G/A and the LVO is an auto G/A. Push the button and let George do his thing. Solution; more recurrency training of a known weakness. Resulting answer; nothing extra at all. Sad day for training departments. No crashes on G?a so no further training required. Incidents? Many, but all survived. Sad days indeed.
I have flown both 737 and 757 as a line pilot, and held TRE on both; on line I've flown go arounds in both types with and without the autopilot. On line I've never had a bad experience but it has been my habit for many years to brief not only the pattern but the physical actions of the go around, and encourage the F.O. to do the same.
By hand or by autopilot it is not a difficult thing on either aircraft, but if you haven't thought it through the startle factor has the potential to make it difficult to manage correctly. I have watched 2 TREs botch an all engines go around in the sim when they went around having expected to land off an approach, they wouldn't have damaged anything but it wasn't pretty.
Anyone can get it wrong, dealing with the stress after that can be very difficult.
By hand or by autopilot it is not a difficult thing on either aircraft, but if you haven't thought it through the startle factor has the potential to make it difficult to manage correctly. I have watched 2 TREs botch an all engines go around in the sim when they went around having expected to land off an approach, they wouldn't have damaged anything but it wasn't pretty.
Anyone can get it wrong, dealing with the stress after that can be very difficult.
Startle factor now recognised as pertinent ; 'are you ready ? ' plus take a deep breath for a 'high altitude ' go around now recommended . Not really keen on over criticising post event flight crews but this is not impressive nevertheless . Significant difference between Airbus and Boeing types but Aviate , Navigate, Communicate (ANC) is the Airbus (now) mantra which applies to Boeing as well albeit different . Company issues ref job etc should not be a factor for professional and appropriate conduct unfortunately missing in this case . Report is a horror story and regardless of seniority number the LHS competency is not at the level required. All engine go arounds continue to cause industry wide problems so will probably appear as an exercise within ATQP sessions more frequently . Sobering and thought provoking post - mortem in and out of TC undoubtedly .
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The big learning point I think that should be taken from this is that when a GA is required from well above minima and in good WX, it may well catch you by surprise, but there is no desperate rush, just a couple of seconds of thought can avoid a lot of heartache thereafter. Regular briefing and mental rehearsal can help greatly (as with the RTO). I do likewise for GPWS and Terrain escape Manoeuvres during which there will likely not be time to ponder! If WX is close to minima, briefing carefully the GA and required actions inc monitoring from the PM required - also a v short 'hot' brief covering the pertinent actions at say between 1000-500R I find is useful.
On approach, ensure thumb is guarding behind the GA switch, not beside the AT Disc button - guards against the motor slip of disconnecting the AT instead of pressing GA. If the AT is to be disconnected, move thumb from GA switch to AT disc switch - press twice - then back to guard the GA switch. Both pilots check GA/GA/GA/CMD
Every approach should be flown as a potential GA.
Know how to fly the aircraft manually and remember the approx datums (that the FD's/AT use during day to day Ops):
T/O & GA - initial 15deg nose up - TO/GA thrust 1.60 EPR (will do)
Accel - 10 deg nose up - 1.50 EPR (will do)
Clean level - 4-5 deg nose up - 1.18 EPR (will do)
If FD are not giving you what you expect, AP disc (as it was in this case), both FD's off, back on (V/S, HDG HOLD) then start again.
On my current operators 2 day recurrent check we are doing 2 or 3 two engine G/A's per crew. A good idea as a botched 757 GA has very nearly caused a hull loss before - see Icelandair incident (very informative read) - I would say approx 1/3 to 1/2 of the line crew are making 'sloppy' or occasionally worse errors with the manoeuvre. Worth covering..
Current B757/B767 TRE/TRI/Base Trainer
On approach, ensure thumb is guarding behind the GA switch, not beside the AT Disc button - guards against the motor slip of disconnecting the AT instead of pressing GA. If the AT is to be disconnected, move thumb from GA switch to AT disc switch - press twice - then back to guard the GA switch. Both pilots check GA/GA/GA/CMD
Every approach should be flown as a potential GA.
Know how to fly the aircraft manually and remember the approx datums (that the FD's/AT use during day to day Ops):
T/O & GA - initial 15deg nose up - TO/GA thrust 1.60 EPR (will do)
Accel - 10 deg nose up - 1.50 EPR (will do)
Clean level - 4-5 deg nose up - 1.18 EPR (will do)
If FD are not giving you what you expect, AP disc (as it was in this case), both FD's off, back on (V/S, HDG HOLD) then start again.
On my current operators 2 day recurrent check we are doing 2 or 3 two engine G/A's per crew. A good idea as a botched 757 GA has very nearly caused a hull loss before - see Icelandair incident (very informative read) - I would say approx 1/3 to 1/2 of the line crew are making 'sloppy' or occasionally worse errors with the manoeuvre. Worth covering..
Current B757/B767 TRE/TRI/Base Trainer
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Aviate , Navigate, Communicate (ANC) is the Airbus (now) mantra which applies to Boeing as well albeit different .
Really? I'm a Boeing man and never known anything different. It was drummed into me in B732 days and I've been drumming it into every student I had on B757/767/737 over the last 25 years. Plus: Attitude, attitude, attitude and power as necessary = performance.
An RTO is never a surprise; take off is a bonus: a Go Round is never a surprise; landing is a happy conclusion to the approach. Somewhere on approach run through the G/A actions in your mind. An ATC wave off is always a possibility; an unstable approach at 500' is always a possibility; a quick shift in wind at low level causing a float is always a possibility: the G/A is never a surprise and should be a doddle to the alert airman. It's what the pax expect. Professional standards at all times.
Really? I'm a Boeing man and never known anything different. It was drummed into me in B732 days and I've been drumming it into every student I had on B757/767/737 over the last 25 years. Plus: Attitude, attitude, attitude and power as necessary = performance.
An RTO is never a surprise; take off is a bonus: a Go Round is never a surprise; landing is a happy conclusion to the approach. Somewhere on approach run through the G/A actions in your mind. An ATC wave off is always a possibility; an unstable approach at 500' is always a possibility; a quick shift in wind at low level causing a float is always a possibility: the G/A is never a surprise and should be a doddle to the alert airman. It's what the pax expect. Professional standards at all times.
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A lot of talk about GA, most can do this OK from normal GA height, it is when you do this from height it catches people out - try it in the sim with a level off at 2,000' and given the GA at 1600' or even worse 2,100', it will catch many out who think they know how to do it!
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As was said in 'comments on the AV report article' the G/A was advised at a decent height. There was no rush. We are conditioned to making G/A's at minima with minimum height loss. Here was a case where there was no need to panic/rush. There was no need to minimise height loss; it could all be done in a leisurely manner. That involves a clear understanding of the manoeuvre and a good situational awareness. A G/A should not be a 'trained monkey' manoeuvre; there are variations on a theme and an alert pilot should feel able to adjust the basic manoeuvre to suit the scenario. The approach could have been continued to a lower height and then when ready, and communicated to the PM, a relaxed G/A initiated. Crews should feel relaxed about exercising judgement in such situations.
I feel simulator scenarios do not reflect enough 'real world' scenarios and thus there are 'real world training' opportunities missing. This is not the first such mess up, and perhaps not the last. I've seen even worse in the sim. "Go Round" called, power added and the a/c descended down the glide path because TOGA had not been pushed. The FD was still in Glide Slope. Ouch. Where was the motor action of raise the nose to a basic attitude to convert descent into a climb? Look through the FD.
Will the lessons be learned? Hopefully.
I feel simulator scenarios do not reflect enough 'real world' scenarios and thus there are 'real world training' opportunities missing. This is not the first such mess up, and perhaps not the last. I've seen even worse in the sim. "Go Round" called, power added and the a/c descended down the glide path because TOGA had not been pushed. The FD was still in Glide Slope. Ouch. Where was the motor action of raise the nose to a basic attitude to convert descent into a climb? Look through the FD.
Will the lessons be learned? Hopefully.
A lot of talk about GA, most can do this OK from normal GA height, it is when you do this from height it catches people out - try it in the sim with a level off at 2,000' and given the GA at 1600' or even worse 2,100', it will catch many out who think they know how to do it!
Indeed, 'there was no rush'.
During my first go-around, years ago as a very green FO, my training Captain calmly told me our speed was a little high and was I ready for a go-around. I said yes and we performed the manoeuvre calmly. More recently, now as a Captain myself, upon receiving an unexpected out of limits wind report I asked my FO an identical question and the outcome was the same. Taking a breath makes all the difference, but I accept that it's not always possible to do so.
Most jet aircraft can be a handle once the TOGA is pressed and we do not practice 2 engine go-arounds enough in the sim due to time constraints, but essentially it is not a complicated manoeuvre especially if the non-flying pilot is proactive. Similar to a normal departure?
But if you both get behind the aeroplane it is very tricky to recover. And this crew never got the chance to take a deep breath and re-mount their runaway steed. IT never rains, it pours!
During my first go-around, years ago as a very green FO, my training Captain calmly told me our speed was a little high and was I ready for a go-around. I said yes and we performed the manoeuvre calmly. More recently, now as a Captain myself, upon receiving an unexpected out of limits wind report I asked my FO an identical question and the outcome was the same. Taking a breath makes all the difference, but I accept that it's not always possible to do so.
Most jet aircraft can be a handle once the TOGA is pressed and we do not practice 2 engine go-arounds enough in the sim due to time constraints, but essentially it is not a complicated manoeuvre especially if the non-flying pilot is proactive. Similar to a normal departure?
But if you both get behind the aeroplane it is very tricky to recover. And this crew never got the chance to take a deep breath and re-mount their runaway steed. IT never rains, it pours!