Thomas cook b757 incident, what a total mess
Problem as I see it is the training and lack of practice of the manoeuver.
In the SIM, every 6 months, we do one all-engine GA, and one with failed critical engine(s).
That's usually it. We are expecting it* and it's usually flown 'near enough' for the tick in the box. If it is not, the instructor will say that they are just positioning you back to 4 miles to 'see it again' The second attempt will almost always be a pass.
However, the same 'competancy' applied to the end of a long day/night with low - but legal - fuel, and an unexpected* event in the real sky with real passengers (instead of a SIM in which you cannot die or even crash), can in some cases reveal shortcomings. The ATC Go-around command and the automation issue is a total red herring, but the type change in this case has relevance in that possibly the Commander reverted to previous type.
I think that critical manoeuvres such as this should be properly practised. Not just once or twice, but over and over, so it becomes a motor memory and refined and absolutely clear in the mind.
Otherwise, we are just going backwards. Despite all the lessons learnt by crashes over the years, we are taking less and less fuel, and less contingency fuel. And training is becoming less and less about basic flying and more about the latest SOP change or whim of the training departments. Training Captains often have so much new stuff to get through that there isn't time to make absolutely sure about pilot's basic skills, as long as they pass.
Also in the SIM, it is a very artificial environment. ATC is very restrained - you are the ONLY aircraft on frequency. There are no helicopters transiting the threshold ahead of you. PNF has not had to talk to company, or the handling agents. You have not been turned in tight or been left hot and high by ATC. You have not been told to keep the speed up or slow to minimum approach speed while they get one away ahead of you. You don't have the beep beep beep distraction of the cabin secure call. The visuals are usually not very good. I have never had rain or turbulence on approach in the SIM.
*Of course we should all expect the unexpected, but sometimes we don't. In view of this TC incident and my own experience, I am going to make an effort now to brief the actual go-around actions and selections, pitches, speeds etc that I will make in the event of a Go-around and those of the PNF, rather than just saying 'ahead to 3000 feet accelerate and then turn east' or whatever. I appeal to my fellow pilots not to glaze over when I do this, but to pay full attention.
(In case there is any confusion, I am nothing whatsoever to do with the incident under discussion !)
In the SIM, every 6 months, we do one all-engine GA, and one with failed critical engine(s).
That's usually it. We are expecting it* and it's usually flown 'near enough' for the tick in the box. If it is not, the instructor will say that they are just positioning you back to 4 miles to 'see it again' The second attempt will almost always be a pass.
However, the same 'competancy' applied to the end of a long day/night with low - but legal - fuel, and an unexpected* event in the real sky with real passengers (instead of a SIM in which you cannot die or even crash), can in some cases reveal shortcomings. The ATC Go-around command and the automation issue is a total red herring, but the type change in this case has relevance in that possibly the Commander reverted to previous type.
I think that critical manoeuvres such as this should be properly practised. Not just once or twice, but over and over, so it becomes a motor memory and refined and absolutely clear in the mind.
Otherwise, we are just going backwards. Despite all the lessons learnt by crashes over the years, we are taking less and less fuel, and less contingency fuel. And training is becoming less and less about basic flying and more about the latest SOP change or whim of the training departments. Training Captains often have so much new stuff to get through that there isn't time to make absolutely sure about pilot's basic skills, as long as they pass.
Also in the SIM, it is a very artificial environment. ATC is very restrained - you are the ONLY aircraft on frequency. There are no helicopters transiting the threshold ahead of you. PNF has not had to talk to company, or the handling agents. You have not been turned in tight or been left hot and high by ATC. You have not been told to keep the speed up or slow to minimum approach speed while they get one away ahead of you. You don't have the beep beep beep distraction of the cabin secure call. The visuals are usually not very good. I have never had rain or turbulence on approach in the SIM.
*Of course we should all expect the unexpected, but sometimes we don't. In view of this TC incident and my own experience, I am going to make an effort now to brief the actual go-around actions and selections, pitches, speeds etc that I will make in the event of a Go-around and those of the PNF, rather than just saying 'ahead to 3000 feet accelerate and then turn east' or whatever. I appeal to my fellow pilots not to glaze over when I do this, but to pay full attention.
(In case there is any confusion, I am nothing whatsoever to do with the incident under discussion !)
Last edited by Uplinker; 15th Oct 2014 at 13:41.
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AUTOMATIC G/A OR MANUAL G/A
Its really very simple.we all rarely do a go-around in line flying.if its an automatic/autopilot g/a it is extremely easy, however the main issue is when the a/p has been selected off then a g/a is required for some reason.the answer is to use a sensible (lower ) thrust setting than full g/a power during the early part of the g/a.on the 767 i fly full thrust is 1:47 epr, however manually setting a lower epr of about 1:30 epr will give you a manageable handling situation before you re-engage the automatics and everything will be comfortable.this is the key action.i have been a 757/767 tre since 1990 and am still active at it, works just fine and dandy, believe me.try it.
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I am going to make an effort now to brief the actual go-around actions and selections, pitches, speeds etc that I will make in the event of a Go-around and those of the PNF, rather than just saying 'ahead to 3000 feet accelerate and then turn east' or whatever.
It has been mentioned in ours too, but not in SOP's
But nobody actually does it !
But nobody actually does it !
Last edited by Uplinker; 16th Oct 2014 at 06:41.
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Piltdown Man wrote:
Foresight is not used but hindsight is and now the lawyers are involved, unless every operator waives airport/ATC liability in the event of an incident, this is how it will stay. As I said earlier, here a "possible" strike would allow us to offer a discretionary landing. A "confirmed" strike would not.
In Ottawa, a crew lands long on a wet runway in an aircraft not equipped with reversers and runs off the end and their company sues the airport and ATC. Everyone is to blame except those directly responsible it seems.
Go-arounds are not uncommon, especially at high density airports, and we are continually told to try and reduce the number but not slow down the throughput of traffic. Figure that one out.
If a professional crew does not handle the go-around correctly because of reasons unknown (but heavily speculated) how is ATC to blame for initiating the go-around for whatever reason? We don't just randomly issue a go-around. We are following our rules and if pilot training is lacking or fatigue/stress/illness is found to be a factor, then things will have to change on the flight deck not in ATC.
This also shows their complete and utter lack of foresight. I believe that it is correct for ATC to pass on relevant information at the appropriate time but to insist on a go-around following a possible birdstrike is reckless bordering criminal. Let us decide. Because if one these go-arounds goes wrong, where will the lawyers look? At us obviously, but also at the controller and the pathetic policy they were asked to follow - all beautifully recorded.
In Ottawa, a crew lands long on a wet runway in an aircraft not equipped with reversers and runs off the end and their company sues the airport and ATC. Everyone is to blame except those directly responsible it seems.
Go-arounds are not uncommon, especially at high density airports, and we are continually told to try and reduce the number but not slow down the throughput of traffic. Figure that one out.
If a professional crew does not handle the go-around correctly because of reasons unknown (but heavily speculated) how is ATC to blame for initiating the go-around for whatever reason? We don't just randomly issue a go-around. We are following our rules and if pilot training is lacking or fatigue/stress/illness is found to be a factor, then things will have to change on the flight deck not in ATC.
If a professional crew does not handle the go-around correctly because of reasons unknown (but heavily speculated) how is ATC to blame for initiating the go-around for whatever reason? We don't just randomly issue a go-around. We are following our rules and if pilot training is lacking or fatigue/stress/illness is found to be a factor, then things will have to change on the flight deck not in ATC.
Absolutely correct, Cossack, well said.
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Poorly flown go around or not...it's what happened afterwards which was scary. Completely miss handled. I'd expect more from a PPL holder...yet here we have 2 ATPL holders. Tragic. Higher standards required in TCX maybe?
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Uplink & Cossack
Maybe not directly to blame but certainly another Link/slice of cheese to add to the sequence. Not that I disagree about the subsequent mishandled event.
Maybe not directly to blame but certainly another Link/slice of cheese to add to the sequence. Not that I disagree about the subsequent mishandled event.
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To me it seems a bit unreal blaming ATC for issuing a reasonable command to the crew. What if they had instructed them to go around at 250 agl instead of a lot further out and the initial part of the GA had been flown as badly.That would have got them very very close to terra firma. Doesn't bear thinking about does it?
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FFS!
When I questioned the reason for the G/A I didn't blame ATC for this mishap. Two completely different issues but shouldn't we be able to discuss both?
When I questioned the reason for the G/A I didn't blame ATC for this mishap. Two completely different issues but shouldn't we be able to discuss both?
Greek,
Yes; another hole in the cheese, but ATC are entirely justified if they see a need to order a go-around. If two pilots cannot handle such an order, then it is down to them and their training alone, NOT ATC.
As I say, (and you agree), SIM training has become so involved these days that basic flying skills are rarely, if ever, given sufficient practice time.
I mean, a concert violinist - or any professional musician - can, and often does practice every day. BA pilots can use their SIMs during down time, but how are most pilots supposed to keep their skills sharp when they do something just once or twice every 6 months?
Yes; another hole in the cheese, but ATC are entirely justified if they see a need to order a go-around. If two pilots cannot handle such an order, then it is down to them and their training alone, NOT ATC.
As I say, (and you agree), SIM training has become so involved these days that basic flying skills are rarely, if ever, given sufficient practice time.
I mean, a concert violinist - or any professional musician - can, and often does practice every day. BA pilots can use their SIMs during down time, but how are most pilots supposed to keep their skills sharp when they do something just once or twice every 6 months?
Surely both of these blokes will have done multiple two engined go-arounds while doing AWOPS in the Sim?
The fact that they both utterly failed to manage any aspect of the operation afterwards is something else. Just how bad do you have to be before the "everyone makes mistakes, they need re-training' mob will eventually see sense?
The fact that they both utterly failed to manage any aspect of the operation afterwards is something else. Just how bad do you have to be before the "everyone makes mistakes, they need re-training' mob will eventually see sense?
I Have Control
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Theory
Innumerable SOP changes, daily issue of contradictory Flight Crew Information Bulletins, over complex trapping sims, and forced demotions, base changes, and TYPE CHANGES. Put all these together, and create a blame culture presided over by outsiders, and what do you get????
Just a hypothesis folks, no finger-pointing. This scenario exists in a handful of UK airlines today. And doubtless MH, AF and others bear a close look too.
And as a secondary but relevant issue, UK ATC are issuing far more go-around orders than in previous years, with no comparable increase in traffic. I have experienced a couple of over-cautious GA orders in the last 6 months, at NCL. and MAN. We managed them fine, but were asking ourselves WTF? as we performed the manoeuvres and were actually quite annoyed about the whole things. (Human reactions) Has the defensive safety culture infected British ATC too? It really doesn't improve safety to be told to go-around for reasons that are more legally protective than practical. (This doesn't let the 757 folks off the hook, but it is a relevant part of the Swiss cheese model).
Just a hypothesis folks, no finger-pointing. This scenario exists in a handful of UK airlines today. And doubtless MH, AF and others bear a close look too.
And as a secondary but relevant issue, UK ATC are issuing far more go-around orders than in previous years, with no comparable increase in traffic. I have experienced a couple of over-cautious GA orders in the last 6 months, at NCL. and MAN. We managed them fine, but were asking ourselves WTF? as we performed the manoeuvres and were actually quite annoyed about the whole things. (Human reactions) Has the defensive safety culture infected British ATC too? It really doesn't improve safety to be told to go-around for reasons that are more legally protective than practical. (This doesn't let the 757 folks off the hook, but it is a relevant part of the Swiss cheese model).
Last edited by RoyHudd; 16th Oct 2014 at 16:59.
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You could blame the pilots for not being able to fly, use airmanship etc etc but what would be the reasons for them to behave in such a way.
Personally don't believe the sim is where we are properly equipped to deal with such calamities properly. It is purely and simply what the other old timers have said. A typical airline has now become one which strives to satisfy the insurers requirements and needs. Training is all about ticking the box and manual flying is not only fully discouraged by disallowed to within a few hundred feet of a runway. Where, manual thrust control isn't allowed yet is a go item on MEL. What do you expect from all of this. No familiar with MPL but this full exacerbates the foundation of checklist flying.
It can happen to any of us and just like what happened here, at the end of a long day when we have the feeling of reaching home and dry, be bitten by something of this sort. What steps will the industry take in better equipping it's pilots (who are also not allowed to conduct private flying in their free time).
Personally don't believe the sim is where we are properly equipped to deal with such calamities properly. It is purely and simply what the other old timers have said. A typical airline has now become one which strives to satisfy the insurers requirements and needs. Training is all about ticking the box and manual flying is not only fully discouraged by disallowed to within a few hundred feet of a runway. Where, manual thrust control isn't allowed yet is a go item on MEL. What do you expect from all of this. No familiar with MPL but this full exacerbates the foundation of checklist flying.
It can happen to any of us and just like what happened here, at the end of a long day when we have the feeling of reaching home and dry, be bitten by something of this sort. What steps will the industry take in better equipping it's pilots (who are also not allowed to conduct private flying in their free time).
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Roy Hudd and Two Tone 7, I wish we has a "like" button for posts like yours! As for companies hand flying policies, what is published in the manuals and what is pushed by local managers can differ wildly, and so many of our profession will toe the line drawn by their immediate superior rather than just do what they should. How extreme this problem is depends a lot on the individual pilot, manager and company.
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Let's just blame the pilots and leave it there!! Come on guys!!
Was this not actually an issue about fuel, and a crew that were understandably in a somewhat concerned nature. Especially, as mentally 1 minute earlier they were probably thinking which exit would they use.
Was this not actually an issue about fuel, and a crew that were understandably in a somewhat concerned nature. Especially, as mentally 1 minute earlier they were probably thinking which exit would they use.
Was this not actually an issue about fuel,
The real question is why did this guy not perform the way he has demonstrated that he can perform? Stress? Fatigue? Brain aneurism ?
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It is right and proper that in this incident we separate the (rather pointless) ATC initiated go-around from the actions of the crew. Because it is totally reasonable that ATC should expect us to be able to execute a go-around whenever they say. However, I think we are entitled to ask why go-around instructions are issued. But I don't think we'll get the real answer because managers with highly risk adverse parish council mentality have moved into ATC management. These people will whip out their safety flags, H & S credentials and "you can never be too careful" statements and attempt to bluster their way around the real issues. An example, although totally off this thread, is the quoting of "threshold elevation" on the ATIS of Scottish FIR airports. Someone has seriously lost the plot.
So Cossack - Can you tell me how safety is improved by ordering a go-around? Just because a procedure is written down it doesn't mean to say it has value. As someone has written earlier, a dead bird or bunny on the runway killed by the preceding aircraft will be one less for the following aircraft to bump into. Ingestion is just smoke-screening the real issue, backside covering pointless edicts from above. Tell us and let us decide.
Returning to the flying training issues:
Not necessarily and besides, you know it's coming. You will have prepared during the previous few weeks and rehearsed the words like an Shakespearean actor and delivered the required performance on the day. LOFT exercises in the SIM are also a 'hop through the hoops' jobs and for many, it's a "get out of the SIM ASAP". A colleague (who is also an instructor) I know once commented as he went into the main section housing the SIMs "Can you smell it?" "What?" asked our instructor. "Fear!" he said "The smell is leaking out from all of these moving boxes." And that sums it up. We are forced to deliver on time, on budget and failure to do so results an uncertain future - one that could have huge repercussions for you and your family. I'm lucky, I can handle it but there are many who can't.
It is fair to say we waste vast amounts of time pratting about with ridiculous scenarios. Ones that could be better handled in classrooms and/or procedure trainers. A better investment might be to spend some SIM time handling the second tier most likely to occur events or ones requiring complex handling procedures - two engine go-arounds, wave-offs, engine failures other than at V1, bird-strikes, lightning strikes, instrument failures etc. But having said that, our company's (re-current) type training programme is trying to do this and we are getting results. But we still have a long way to go but there are many companies who will have further to travel.
This TCX incident merely highlights the holes in our systems. Both our training and checking is deficient and needs looking at.
So Cossack - Can you tell me how safety is improved by ordering a go-around? Just because a procedure is written down it doesn't mean to say it has value. As someone has written earlier, a dead bird or bunny on the runway killed by the preceding aircraft will be one less for the following aircraft to bump into. Ingestion is just smoke-screening the real issue, backside covering pointless edicts from above. Tell us and let us decide.
Returning to the flying training issues:
Surely both of these blokes will have done multiple two engined go-arounds while doing AWOPS in the Sim?
It is fair to say we waste vast amounts of time pratting about with ridiculous scenarios. Ones that could be better handled in classrooms and/or procedure trainers. A better investment might be to spend some SIM time handling the second tier most likely to occur events or ones requiring complex handling procedures - two engine go-arounds, wave-offs, engine failures other than at V1, bird-strikes, lightning strikes, instrument failures etc. But having said that, our company's (re-current) type training programme is trying to do this and we are getting results. But we still have a long way to go but there are many companies who will have further to travel.
This TCX incident merely highlights the holes in our systems. Both our training and checking is deficient and needs looking at.
Well said, except we should all be able to execute a go-around whether ordered by ATC or not, so their involvement here is irrelevant.
FANS: I'm sure low fuel was a stress factor. Why do the CAA/ICAO allow us to carry such low fuel?
I have seen a real go-around handled badly. I know of a real EFATO where the gear wasn't brought up. These examples were both 'flown' by experienced captains, one of whom was a training captain.
As I suggest in post 143, perhaps we need to get back to the basics in the SIM and practice each manoeuvre say 10 times, not just once every 6 months.
A motor memory needs to be frequently practised otherwise it will fade.
FANS: I'm sure low fuel was a stress factor. Why do the CAA/ICAO allow us to carry such low fuel?
I have seen a real go-around handled badly. I know of a real EFATO where the gear wasn't brought up. These examples were both 'flown' by experienced captains, one of whom was a training captain.
As I suggest in post 143, perhaps we need to get back to the basics in the SIM and practice each manoeuvre say 10 times, not just once every 6 months.
A motor memory needs to be frequently practised otherwise it will fade.