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TransAsia in the water?

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TransAsia in the water?

Old 5th Jul 2015, 19:24
  #721 (permalink)  
 
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In the old days...
...people died far more frequently and pilots opposed the introduction of cockpit voice recorders. Things have changed for the better since then.
Apples and oranges. In the old days, most pilots had a couple engine failures or shut-downs every year.

Requote: 'Engineering has changed for the better since then....'. Trouble is, I'm not sure that not getting any real-time experience has done much for piloting skills.
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Old 6th Jul 2015, 08:09
  #722 (permalink)  
 
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it looks like any ATPCS triggered event. But why?
I propose you read the preliminary report. Especially the "Airworthiness Group" part.
It was a faulty torque sensor signal line (a cracked solder joint) which caused the AFU to autofeather a perfectly running engine.
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Old 6th Jul 2015, 09:35
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This is not a case of harking back to the good old days, nor should we be sidetracked by the need to quickly shut down in case the autofeather hasn't worked.
This is a clear case of failure to follow the correct sops, the FCOM and the correct shutdown procedure.

The report shows us what the screen would be like in the event of an engine failure of this sort. It tells you what to do, moving the power leaver to idle is item number 12 on that list. So even if you forgot the memory items, the aircraft reminds you!
It even tells you which leaver to move (1or2)
Whilst an engine failure is not run of the mill and your heart will be in your throat, with adequate training this should not be a major problem.
Training and rigorously applied basic standards.

Of note though the EWD screen shows white for Eng1, this is a non normal display and could be the reason why Capt A assumed Eng 1 was the problem. Not excusing just pointing out a possible physiological reason for his actions.

Although I point out the obvious failures, we should look at the reasons for them. Never assume you are immune from making the same mistake.

Dirty Prop;
Although Capt A had nearly 5000 total time only 250 odd was on this particular type!
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Old 6th Jul 2015, 10:21
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Never assume you are immune from making the same mistake.
Absolutely - never was a truer statement made!
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Old 18th Jul 2015, 22:50
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...............OEB 29!
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Old 19th Jul 2015, 11:20
  #726 (permalink)  
 
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Well as we see from the report on BA, shutting down engines against procedure and without involving the FO isn't limited to Asian airlines, so maybe go easy on the 'cultural' aspects hey?
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Old 19th Jul 2015, 23:51
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This should take you to the beginning of the AFU discussion. http://www.asc.gov.tw/upload/acd_att...ss.pdf#page=27

There is also this; http://www.asc.gov.tw/upload/acd_att...ns.pdf#page=30

Last edited by noalign; 20th Jul 2015 at 00:46.
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Old 1st Jul 2016, 06:38
  #728 (permalink)  
 
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Final Report - TransAsia GE235 Accident

The Final Report on this accident is out:

https://www.asc.gov.tw/upload/acd_at...6-001%20EN.pdf
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Old 1st Jul 2016, 07:51
  #729 (permalink)  
 
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Dangerous crew incompetence: Shutting down wrong engine.
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Old 1st Jul 2016, 09:09
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Firefox is flagging that link as "untrusted"!
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Old 1st Jul 2016, 09:17
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The wrong engine mistake was already known from the preliminary reports. What struck me when reading the findings summary was this:
Captain A’s performance during the occurrence was consistent with his performance weaknesses noted during his training, including his continued difficulties in handling emergency and/or abnormal situations, including engine flame out at take off and single engine operations. However, TransAsia Airways did not effectively address the evident and imminent flight safety risk that Captain A presented.


Regarding the untrusted link, try this instead: http://www.asc.gov.tw/upload/acd_att...6-001%20EN.pdf
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Old 1st Jul 2016, 15:44
  #732 (permalink)  
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Originally Posted by noske
The wrong engine mistake was already known from the preliminary reports. What struck me when reading the findings summary was this:


Regarding the untrusted link, try this instead: http://www.asc.gov.tw/upload/acd_att...6-001%20EN.pdf
Who signed him off? They are surely responsible?
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Old 1st Jul 2016, 23:44
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They tried to restart the good left engine which had been wrongly shut down. This HP compressor had reach 50% when they crashed. With 10 more seconds they might have had enough power to save the flight.
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Old 2nd Jul 2016, 01:03
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GlueBall

Dangerous crew incompetence: Shutting down wrong engine.
I guess you have never sat in the back of a sim, or even sweated a drop while being checked while driving one in the knowledge that everything you had mentally rehearsed was going to happen?

I'll bet also that you didn't even read the entire report (which incidentally I thought was of a very high standard), did you?

Clearly you didn't get as far as page 112 because you had already determined, in your ever so simplistic thought process, that the pilots were incompetent. It seems though that there are many more of them (us) out there that do not own your piloting skill set.....

About half of the accidents involving turboprop aircraft in
the transport category occurred during the take off phase of flight. About 63% of
the accidents involved a loss of control, with most of those occurring following the
propulsion system malfunction during take off. Seventy percent of the ‘powerplant
malfunction during take off’ events led to a loss of control, either immediately or
on the subsequent approach to land.
Propulsion system failures resulting in an uncommanded total power loss were
the most common technical events. ‘Shut down by crew’ events included those
where either a malfunction of the engine occurred and the crew shut down the
engine, or where one engine malfunctioned and the other (wrong) engine was shut
down. Fifty percent of the ‘shut down by crew’ events involved the crew shutting
down the wrong engine."
I'm no statistician, but excluding you perhaps 50% of us pprune readers might also have done it.
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Old 2nd Jul 2016, 08:41
  #735 (permalink)  
 
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Deefer Dog, those stats are referring to accidents*. I think most of us with adequate training are comfortable that we would not be part of the accident group and therefore not part of the 50% who shut down the wrong engine.

*Statistics need to be read very carefully in order to make sense of them. The section is poorly worded and I am not sure if they are referring to accidents or PCM+ICR events (engine failure combined with incorrect crew response). Either way, it is not suggesting at all that 50% of pilots would make a similar error.
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Old 4th Jul 2016, 09:34
  #736 (permalink)  
 
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Shutting down the wrong engine in a multi-crew cockpit could lead one to consider slack training. It might be in an atmosphere of 'rushing' and surely would be in an atmosphere of 'not confirming'. The latter can be caused by a training culture. Some QRH's (memory & non-memory) require PM to "confirm" any control which shuts down an engine. There is, of course, a danger of lip-service to this procedure, but, again, that can be trained out in a strong culture. It does seem a staggering statistic and one which should be addressed to find 'out cause'. Mind you, 50% of 2 is 1, so just how many, here, does 50% represent? I admit to not yet having read the whole report.
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Old 4th Jul 2016, 10:36
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deefer Dog - After engine failure, some rudder input becomes necessary in order to maintain flight path, directional control, heading. Most multiengine students during basic flight training have learned the elementary principle of "dead foot, dead engine." This concept is so instinctive that a good pilot does not need to look at engine instruments to determine which engine has lost power, or in the case of a four engined airplane, on which side the power loss had occured. So I stand by my comment that this crew, especially the PF, was incompetent in the elementary task of identifying the inoperative engine.
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Old 4th Jul 2016, 12:30
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...elementary principle of "dead foot, dead engine." This concept is so instinctive that a good pilot does not need to look at engine instruments to determine which engine has lost power...
Well, if you have a torque runaway or overspeed of some sort, the GlueBall method will lead to shutting down the good engine [running normally]
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Old 5th Jul 2016, 04:22
  #739 (permalink)  
 
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avionimc - the "dead foot, dead engine" technique is an aid in IDENTIFYING an inoperative engine; the actual shutting down of an engine is a separate sequencial phase.
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Old 5th Jul 2016, 11:15
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Originally Posted by GlueBall
deefer Dog - After engine failure, some rudder input becomes necessary in order to maintain flight path, directional control, heading. Most multiengine students during basic flight training have learned the elementary principle of "dead foot, dead engine." This concept is so instinctive that a good pilot does not need to look at engine instruments to determine which engine has lost power, or in the case of a four engined airplane, on which side the power loss had occured. So I stand by my comment that this crew, especially the PF, was incompetent in the elementary task of identifying the inoperative engine.
Glueball incompetent`s a bit heavy. Yes blame does lie with him for shutting down the wrong engine, but he was not alone in such an error, the chaps in the Kegworth crash did just the same and they had the comfort of time and altitude to realise their error, but did they, no they did not. By the very fact that it happened yet again the lessons of the Kegworth crash could not have been learned. Just have a look at the check list, nothing about dead leg anywhere on it. So the blame does not lie solely on the shoulders of the unfortunate crew. Most are taught on piston twins, lethal on single engine out on t/0, and the dead leg dead engine bit is drilled into them at that stage. But once they move onto the big and heavy machines they leave all that behind for the sophistication of automated systems. In this instance it was the AFU that was the first element in the causal chain. An essential piece of kit for a large turbo prop twin, without which it would require both legs of an Olympic wrestler to feather the great big paddles and keep the thing right way up. I just wonder for the ATR, as to where the AFU sits, on the DEL or MEL. I`d be surprised if it is on the deferred.
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