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Thomas cook b757 incident, what a total mess

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Thomas cook b757 incident, what a total mess

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Old 13th Oct 2014, 14:22
  #81 (permalink)  
 
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ironbutt57 Eckhard..I suspect you are referring to the "alt hold button"?..equivalent of "push to level" on the Airbus...by pushing in the VS/FPA selector
As far as I know:

Boeing MCP: ALT button will stop climb or descent and level at the altitude that the button was pressed. In other words, an overshoot and then regaining of the altitude.

Airbus FCU: push to level off feature of VS knob has similar effect except the climb descent will stop at whichever altitude is reached when VS is 0. In other words, no regaining of the altitude when the button was pushed.

Airbus FCU: A320 family may have an ALT button or an EXP button mounted in the same space on the panel.
Don't know how the ALT button works as my A319/320/321s don't have it.
EXP button works as previously described.

In my original post I was trying to point out that not all Airbii have an ALT button, although some do. I was answering a previous post which suggested that none had the ALT button.

Confused? I am!
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Old 13th Oct 2014, 14:59
  #82 (permalink)  
 
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click, click = A/P OFF, A/T's OFF.
My fo today went click click click click click click click and that was just for the autothrottle
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Old 13th Oct 2014, 15:00
  #83 (permalink)  
 
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1. Impossible to rule out the human factor effect on the impending demotion. Who would call in sick for feeling demotivated for that? Can you bring your A game under those conditions? Depends on your personality?


2. Small events were taking them out of their comfort zone with each one slowing the brains ability to process information as some brain cells remained stuck asking the question "why did that occur I don't understand"?
a. Negative windshear of 15 knots .
b. failure to capture ILS [LOC] on first attempt.
c. Bird strike report. Go Around!
[First mistake disconnecting auto thrust instead of pressing TOGA no bigee. average pilot bad day at the office has happened endless times in the past and will happen endless times in the future]
d. Attempting to look beyond the flight director during go around.
e. Initial missed approach altitude just 1000 feet above.


3. The Herald report leaves some good points out from the official report
a. The captain said he reverted to "Airbus Mode".
b. The captain admits to thinking of the disciplinary measures for screwing it up while still reading checklist with a lot of work still ahead.
c. Co Pilot was unable to "open" the speed window and set the requested speed.{ can anyone shed light on this}Co Pilot admits to feeling agitated and dejected by what occurred when he started the leading edge checklist.
d. The autopilot repeatedly tripped out.
e.LE slat disagree
f.TE flap disagree
g. Low fuel for diversion
h. fuel pump low pressure light.
I. Fuel imbalance annunciation. [WHY?]
J. the co pilot could not program the fmc for the diversion in "rte 1" and after several attempts had to enter it in "rte 2" or alternate"
K.. Which diversion airport and runway length considerations


You can decide where, but at some point they were fully loaded and that caused everything to go downhill as it will for many crews. If you join the action at about 2000 feet in the missed approach and disregard how they got there for arguments sake, they got it together landed safely and I know several crews flying all over this planet that would have screwed it up far worse from that point onwards.
So many great lessons to learn here
Number one don't get complacent! When you least expect it, Wham its your turn up to bat!
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Old 13th Oct 2014, 15:21
  #84 (permalink)  
 
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you will find it hard to take a step back to catch your breath.
Number one don't get complacent! When you least expect it, Wham its your turn up to bat!
The two wisest sentences in this thread.
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Old 13th Oct 2014, 16:45
  #85 (permalink)  

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I think we have to look more closely at the human factors in this incident. I suffered a nervous breakdown in the air, to the degree that I was effectively a passenger in the LHS while the FO stuffed up an approach. No harm was done, and we landed safely. I hadn't realised what had happened until I saw the FDR readout, at which point I fell apart, and haven't flown since (ten years now). It's only by sheer chance that nothing worse happened; I was a ticking bomb. The cause? Stress, overwork, fatigue. All the things we don't think we suffer from, and the regulators can't (won't?) do anything about.
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Old 13th Oct 2014, 16:57
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Hard to argue with Herod here. I concur. I've felt I've been close enough to similar situations.
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Old 13th Oct 2014, 17:00
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As it was explained to me the EXP button gave climb at Green Dot and Descent at MMo or Vne, this led to several alpha prot or high speed excursions. It was banned from use in our airline before I joined in 2000. Since then, all of our old narrow bodies have been retired and all the new ones have the ALT button instead. All wide bodies, I understand, have ALT button, which has the same function as pushing the VS button. I have also read somewhere that EZY had an incident years ago where someone pushed EXP insted of APPR, which must have caused a bit of excitement.
As regards the thread topic, there but for the grace of God.............
With regards to sim training, IMHO, it has been become more TRAINING and less TESTING, these days I come away from nearly every sim having learnt something new, in the old days I came away from a sim with a huge sigh of relief. Lets not revisit the past, but with the amount we are expected to cover in each detail, maybe more time in the sim for all of us would be beneficial.
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Old 13th Oct 2014, 18:52
  #88 (permalink)  
 
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Back to Basics: I admit I'm an old fart. I learnt to fly on old basic aircraft from GA singles & twins onto biz-jets and B732's. An excellent grounding: and every new pilot should have one.
I/we learnt to fly the a/c and use what ever very basic automation was available to achieve the task, plus motor skills. The basics of a G/round were to convert an approach (descent) into a G/A (climb); reduce the drag and accelerate. Now for a pilot who understands the a/c and its systems and capabilities that is not rocket science.
Over a few good many years I graduated onto these new whizz-bang VNAV LNAV beasts and found them a delight. But never forgot the old techniques. The FD & CDU are a tool; They are not my boss. If it helps then I'll use their information, but I'll decide. There is enough tertiary information to make that judgement, if you've been taught correctly.
Now, for a good (too) many years I've been teaching cadets to fly these even more modern whizz-bang thingies. Now they have SOP procedures coming out of every orifice. They do not understand how to manipulate the a/c, via hands, (FD), CDU or MCP to achieve the required task. They do not think, First? " what do want to achieve?" They first think, " what is the written SOP?" If they become confused due to pressure, loss of memory, panic, confusion, they do not have a basic understanding of 'what do I want to achieve, and how to accomplish it safely.'
If they did they could then operate the a/c within the confines of its design, achieve what is required and sort out the rest later on. As they catch up with the manoeuvre they can slot back into the SOP routine.
Todays teaching is not how to control the a/c in all modes and be in command of this race horse; it is how to operate according to SOP's and nothing else. It's trained monkey and a disaster waiting to happen.
On a good day SOP's will be fine and dandy. On a bad day you need full understanding of the beast you are riding. Pull the wrong reign and you are tipped off. Push the wrong heel at the wrong time and you are over the neck.
When will pilots be trained to control and command their beasts by basic knowledge? Sooner rather than smoking holes later.
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Old 13th Oct 2014, 19:09
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First mistake disconnecting auto thrust instead of pressing TOGA
and I have done the reverse twice on a 737 - pressing TOGA at 300' instead of disconnecting the authrottle and, to compound matters, pressing TOGA a second time being convinced that what I had successfully done was to disconnect the autothrottle. Result - 2 go arounds...
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Old 13th Oct 2014, 19:49
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I have done it twice on the line, pressing TOGA instead of AT disconnect, but the mistake is obvious and easy to correct. I have also done it the other way twice in the sim on single engine go-rounds, flying accurately enough because I tend to look through the FD anyway, using it more to confirm attitudes than to lead me, but didn't consciously recognise the mistake or even that the FD was sill in APP! Those who haven't made that mistake will. A total of four occurrences in 16 years is not atypical, from what I have seen, but having the FD in APP while believing it to be in TOGA could create quite a level of confusion. FMA cross checking helps, but you don't have the opportunity to do that as you press TOGA because you're too focused on the pitch and thrust inputs, config changes and getting away from the ground.
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Old 13th Oct 2014, 20:11
  #91 (permalink)  
 
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It is all very well treating this as though it were just one mistake, a poorly executed g/a, but it wasn't. It was an appalling series of basic blunders and fundamental errors that began with the failure to cope with a cocked up g/a and showed a crews far behind the aeroplane they were unable to recover from one mistake

Any of us might foul up a g/a (worrying as that is in itself) but the knock-on failures that cascaded on from this original incident is surely proof that the crew simply weren't up to the job. Excuses of pressure, base changes arc are utterly irrelevant, it is the Captain's job to retain Captaincy and both of them to retain competency, all of which they manifestly failed to do.

This is a classic case of insufficient competency, clusterf*ck brought about by a single simple error. A crew unable to recover from a simple error like a botched g/a has no business in the business. Sorry, blunt as it is, its the reality. It's also not just an abject failure in technical skills, the highly questionable decision to divert without proper consideration of landing distances required shows an inability to apply reason to the situation too. = total overload - the one drop extra that caused all the water to fall out of the sponge.

You have to wonder at the competency of a crew that can't do a simple non urgent 2 engine g/a , but one that can't cope in all that comes after after this goes awry is way, way out of line.

No excuses for this sort of thing, and everything to do with lack of basic flying skills. Even if after 1400hrs on type (ffs!!) the 13000hr ,guy can't see what his FMAs are telling him he must, MUST be able to pickle the whole shebang and revert to first principles, surely?

But if not...

Last edited by Agaricus bisporus; 13th Oct 2014 at 20:23.
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Old 13th Oct 2014, 23:20
  #92 (permalink)  
 
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So what should be do with this crew then AG? And what should we do with anyone else who doesn't come up to your standards? How will we choose who gets the chop? How will we stop crews practicing for their "chop rides" in the real aircraft with passengers (like people used to do when we could all fly better)? And how many of your colleagues will be looking for new jobs? And when we start assessing other aspects, maybe the non-flying elements of our job, will you be up to it?

This is an example of a crew who got it wrong after having got up in the WOCL and who had been on duty for just over 11 hours, executing a manoeuvre they will have hardly ever practiced or done in real life (I'm lucky, I've done quite a few in the recent past for a whole variety of reasons - usually me). Unfortunately for this crew, after getting the initial action wrong, the rest of the flight continued in a similar vein. The crew were then frustrated because the aircraft appeared to fight them, preventing them from being able to get back in the loop. And let's remember, the captain knew he fouled up the G/A and imagined the consequences (looming internal demotion). Not the best frame of mind to start dealing with a problem, even if it was of your own making.

So what would have helped? Firstly, regular training to do a standard, two engine go-around. I don't think I've done more than ten in 20 years in the sim. In the real thing I've fouled up two - both of which caught me unawares, which is no excuse but I'm sure practice would have helped. But recently, I've being doing rather a few yet I'd still like more practice. But for this crew, once it started going wrong, they had no tool to do the aeronautical equivalent of stopping the world. It just snowballed... There has to be something that would work for a B757 to give a crew 5 -10 seconds of breathing space.

Lastly, this crew is not unique. There are many, many crews like these and the same initial go-around fiasco is highly likely. The same outcome though, is probably less likely. Our training, both in the manually flown past with the ex-airforce choppers and the modern, CRM orientated, mainly autopilot present has many useful bits missing. It's just damn shame that this AAIB report, with 20-20 hindsight, only told us that they crew didn't get it right. And had they done what they should have, then this incident wouldn't have happened. Gosh! What insight. Maybe it was written by the office junior. It wasn't up to their normal standard. A little guidance might have been useful or even some hazard identification.


PS. Their company's internal report does appear to show that TCX has a future because it looks like they understood what happened and that is where you start fixing the real problem.
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Old 13th Oct 2014, 23:45
  #93 (permalink)  
 
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had a brief scan through this whole thread.

No mention has been made of the time this event occurred. If they were at the end of an all night flight, I wonder how much fatigue may have contributed to this event.

Stress and fatigue are all too often ignored .
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Old 14th Oct 2014, 02:08
  #94 (permalink)  
 
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I've also seen a two engine GA completely screwed up on an A320 (of which I was a participant and had to take control from the captain), a cabin crew member asked me afterwards 'were we about to die'. All from a perfectly serviceable aircraft in good weather performing a simple G/A just below missed approach altitude.

I think it would be good to throw in a few G/A calls in sims both above and slightly below missed approach altitude.
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Old 14th Oct 2014, 02:27
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I had to do a go-around during my initial training on a similar type due to an unstable approach. Was new to the advanced aircraft type and during the missed we started getting new altitudes and headings(instead of the nice easy and briefed LNAV and VNAV button pushes at the appropriate times). The VS is very high and the new altitude is approaching fast, and there are lots of dimly lit buttons on the MCP that require pushing quickly and properly. I knew I would screw that up and am glad that I disengaged the automatics and handflew with a brief two hundred foot altitude deviation which I think was within limits.

Sometimes you just have to realize that you are not good enough to handle this stuff and try something different. Since then, I do try to review various go-around actions once in a while because I know it can easily be screwed up. A quick brief of go-around actions including hand movements can be useful to ensuring the right button bets pushed.

I also found myself forgetting to push TOGA during manual go-arounds in the sim. So I have added that to my go-around call to make it more likely that it wont get missed. Not SOP but it can be said silently. "Go-around" TOGA "Flaps___". Or just say it all in a real life go around.
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Old 14th Oct 2014, 02:36
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Agree with your last post, Tom.

Not in any way absolving the crew from their total responsibility for this cock-up, but you're right. G/As on the line rarely happen as per the 'brochure' (at minima). I personally have a couple of 'gates' around the missed approach altitude, through which I determine what AFDS modes other than TO/GA to use.
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Old 14th Oct 2014, 07:33
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No mention has been made of the time this event occurred. If they were at the end of an all night flight, I wonder how much fatigue may have contributed to this event.
The AAIB report states the incident happened at 16:10 UTC (so 17:10 local) after a return flight to the Canaries from Newcastle. Mid August so daylight. Weather reasonably benign.

Arguably, the situation began to develop before the G/A when the crew failed to capture the ILS localiser at first attempt. As a non pilot it's not 100% clear to me why, but the report suggests high speed was a factor - perhaps they should have had a few more track miles to lose the excess knots?

For whatever reason the Captain was, from that point on, developing a thought that there was something wrong with the aircraft.

Was that the first 'hole in the cheese'?

Last edited by Airbanda; 14th Oct 2014 at 10:21. Reason: syntax
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Old 14th Oct 2014, 08:02
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G/As on the line rarely happen as per the 'brochure' (at minima).
A justifying observation:

Engine failures rarely happen nowadays, when they do it is rarely just before or after V1. Yet we always practice just that (some more enlightened companies also throw them in at other times.)
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Old 14th Oct 2014, 08:43
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For those of you who don't do them with regularity, a day to the Canaries from Scotland or the North of the UK is significantly longer duty hours and more flying time than an East Coast sector. It involves probably a 4am alarm, nearly 5 hours sat on your backside, sometimes sporty Canaries approach, all of a sudden, rapid turnaround on the ground, then 5 hours home. If it's your first day on earlies as someone else mentioned you are probably bushed as you didn't sleep that well. Do TCX have a controlled rest policy? If not, did either crew member have a nap in flight anyway?

All information I would rather the AAIB had developed. I am always very careful when driving home after a day like that at the end of a block of duty. Some like them as they're easy money, but I would much rather a shorter or busier day. They really aren't any fun in the winter when after taking off in the dark, you again have to land at night in typically Scottish wind and rain.
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Old 14th Oct 2014, 09:59
  #100 (permalink)  
 
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Engine failures rarely happen nowadays, when they do it is rarely just before or after V1. Yet we always practice just that (some more enlightened companies also throw them in at other times.)

Time for XAA's to rethink their mandatory items. An engine failure before V2. I had one given to me at Go Round from an NPA. The G/A flap setting = V2 Vref, so this was deemed as to comply. It was an excellent opportunity to hone some skills. The surprise factor alone was worth a great deal. Even just at V2 on a takeoff as the gear is selected up. Both are bird strike territory and thus realistic. Between V1 & Vr is really a very small deal. There's no roll. At 50' you have to be sharp, just as the pax expect.

I go back to my basic point a few posts ago. Pilots should learn and be taught in-depth how to control the a/c and make it do what they want; by either manual raw data, manual with AFDS help or use of the MCP and automatics. They should then be allowed to use what ever system is available to achieve the required task as decided by the PF. I've flown for various airlines who all tried to re-invent the wheel. The SOP's all had various personal (CP) tweaks. The a/c were all built the same, all had the same kit, but were treated slightly differently. If in the moment of stress I was hesitant about my accurate memory of the current SOP I reverted to flying the a/c in a basic manner to achieve the task. That's because I understood and knew how to do it. Some people here say that a G/A from height with only a few 100' to level off is hard. Not it's not if you understand the a/c. I once flew B767 with an F/O who was making a teardrop outbound to turn in on an NDB. It was timed outbound with no DME; at night CAVOK with PAPI. It was a descending manoeuvre; no big deal. The MAA was 2500'. AT 1000' on finals it was obvious he was hot & high. Nothing was happening; he was fixated, so I suggested a G/A. At which point he slammed on full thrust and we rocketed skywards. With some exasperated coaching he managed to regain control of the V/S. The idea had been to retract to mid-flap setting fly a visual circuit at MAA and try again. On later discussion about how we ended up in that state his reply was, "you called Go Round, so I did what was normal." A B767 at light weight and full power is a rocket ship.
The other often heard claim about chaos waiting in the wings is a Go Round when above MAA. Agh! Disaster waiting to happen, we hear. There have been other calm voices on here whose first reaction would be to take a deep breath.
Good thinking, Batman. Then use the controls & AFDS as necessary to achieve the task required in a calm manner. Having confidence in understanding the /c and systems allows this. That is more important than practice. Practice is too often trained monkey repetition.
I flew with one company that insisted a G/A be completed 100% and then a re-brief made for the next attempt, even on a visual CAVOK day. It was not allowed, as was ably demonstrated one day by another airline, to climb out, retract flaps to a mid-setting, turn downwind into a visual circuit and land: all the while staying on tower frequency. Thus the G/A involved climbing up to a high altitude, changing to approach at another airfield, return to the beacon and start all over again. Thus, crews knew only one method of doing a Go Round. This was what was written down; they did not know, or have discretion, to use the necessary to achieve task efficiently and expeditiously.
So, when the G/A is commenced from an unfamiliar point they are lost. Sad days.
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