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Emirates B777 gear collapse @ DXB?

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Emirates B777 gear collapse @ DXB?

Old 13th Sep 2016, 09:13
  #1481 (permalink)  
 
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because they were either regressing to procedures learned on a previous type,
You're on the wrong track with that bit IMO.
If you are in a 737 the aircraft is 'bridled and saddled' as you put it (99% of time). I don't know about other airliners but the 777 is nearly always landed with automatics controlling the thrust.
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Old 13th Sep 2016, 09:39
  #1482 (permalink)  
 
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Ref Buzzbox: Many thanks; finally some facts about what will happen and what should happen; i.e. be done. Plus some insight into training for these scenarios.

I make 3 comments.

1. A rejected landing after wheel touch down and speed brake up is not an EASA mandatory manoeuvre. The 'wave off' at 50' is. However, on the LST form this is called a 'rejected landing'. IT IS NOT. It is a low level GA with engines probably at medium thrust levels and sufficient height, perhaps, to avoid ground contact. It is a STANDARD GA.
2. If a real rejected landing, as per FCTM definition, there are some significant notes of difference. PF will call Go Round and increase thrust; speed brakes & auto brakes should stow & disconnect; accelerate and at Vref PM calls Rotate; do not change flap on the runway.
3. rotate should be commenced no later than 2000' from the end of the runway.

This manoeuvre can be executed for a number of reasons including a long landing with insufficient runway to stop. How many events have there been in the world where this manoeuvre executed correctly would have avoided tragedy? Is it a mandatory trained Manoeuvre? NO. WHY NOT?
It has been said many times that the all engine GA is one of the most screwed up, least practiced manoeuvres of all. This variant has huge potential for screw up and yet is often not trained at all, nor practiced. XAA's & training depts need to look at themselves very closely.

I had always assumed that landings were conducted with the thrust levers in hand and held with vigilance should their immediate use be required.

Precisely. Many over-runs might have been avoided if the landings had been conducted with a GA, even rejected landing, mentality other than a 'must land-itis' thinking. That is why I beat their knuckles when I saw cadets, even seasoned F/O's, flaring with their hands on the Thrust Reversers. It required quite an eye-opening discussion to explain why it was NOT a good idea, and a further refresher of the braking system to explain why it achieved zilch. What was worse was the panic s election of reverse accompanied by disarming of the auto brakes with feet after a F30 landing to make a short turnoff; even on a damp runway.

Back to the point of why is rejected landing not a mandatory trained manoeuvre? It is all very well to make a simple statement that a Go Round can be made from the runway up into the TR's have been deployed. It is quite another not to train crews to do it, both mentally & physically, especially as it is different from a GA. In various NTSB reports there has been criticism of airlines who had not trained crews in certain manoeuvres, which would have helped avoid an incident/accident, or trained them incorrectly; e.g. AA rudder failure after wake turbulence. In these cases training programs were changed. It will be interesting to see what recommendations are made after this report is concluded and if this manoeuvre replaces the 'normal GA from 50' in the LST.

Last edited by RAT 5; 13th Sep 2016 at 10:01.
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Old 13th Sep 2016, 10:25
  #1483 (permalink)  
 
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RAT 5,
Well said.
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Old 13th Sep 2016, 10:35
  #1484 (permalink)  
 
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I tend to agree with RAT 5, in so far as, I believe this crew could have, like many, been set up to fail here.

Just a point of information. At my employer, PF does NOT operate reversers! That is a job for PM. That simple fact allows me to pre-brief that PF does not remove their hand from the thrust levers unless they are happy we can stop, AND PM does not select reverse unless they are also happy we can safely stop. Either pilot can call go-around. We both have a very immediate investment, and clear responsibility, in the landing! ONLY when reverse is selected, are we committed to completing the landing! Not before.

At which point in the brief, a quick resume of HOW we would conduct a go-around after landing is included. It's debatable whether I would have thought such a briefing relevant before landing on a 4000m runway. However, we land on short runways so frequently that the 'how' is always reasonably fresh in the mind. Coincidentally I did one in the sim a month or so ago, and I think it may have been part of that recurrent?

I can see that Airbus has a more robust procedure for this particular manouvre. I can also see that something they do differently would have gone some way to mitigating what occurred here. It was always hammered into me on the Airbus that go-around thrust is selected, (which on the Airbus ALWAYS requires you to fully advance the thrust levers!) and flap is retracted one stage. THE NEXT STEP IS TO READ OUT LOUD THE FMAs! If they annunciate what you want to see, (would be THR/TOGA/TOGA on a Boeing) THEN gear is raised!

Incidentally, you can go-around quite easily with the gear down. Ask me how I know! But as we saw here, you can't go-around if the FMAs aren't correct!!

I would suggest to expect a recommendation to the manufacturer to include FMAs at a very early stage in all go-arounds. This simple change could have mitigated our colleagues incorrect actions. It helps to protect us all.

Last edited by 4468; 13th Sep 2016 at 10:45.
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Old 13th Sep 2016, 10:46
  #1485 (permalink)  
 
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Recommendations must surely have gone out already regarding the parlous state of the slides. To learn that only one door was unaffected( except by fire outside!) makes the evac of everyone before the tank blew an epic feat. Presume the slide state is down to its age and little usage as well as the elements.
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Old 13th Sep 2016, 11:03
  #1486 (permalink)  
 
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Originally Posted by alf5071h View Post
Based on what is currently known, this was a 'normal', SOP, accident.
The crew followed normal procedures and behaved as they had been trained and had practiced many aspects in everyday operations; except, apparently, for one oversight in not checking the thrust increase for an infrequently encountered situation, and a specifically exceptional circumstance.
I think it is bit too early to prep the crowds for the final report.
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Old 13th Sep 2016, 12:29
  #1487 (permalink)  
 
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FMA callouts

Originally Posted by 4468 View Post
I would suggest to expect a recommendation to the manufacturer to include FMAs at a very early stage in all go-arounds. This simple change could have mitigated our colleagues incorrect actions. It helps to protect us all.
This is already SOP.
It is not specifically included in the written Go Around (or any) manouevre flow, because it is identified at a higher level of SOP.
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Old 13th Sep 2016, 14:31
  #1488 (permalink)  
 
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Just a clarification - it is possible to abort a landing after selecting reverse thrust as a last resort if the situation dictates (e.g. another aircraft or vehicle on the runway). It's something Boeing now designs for - the so called "Cranbrook scenario".
https://en.wikipedia.org/wiki/Pacifi...nes_Flight_314
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Old 13th Sep 2016, 14:46
  #1489 (permalink)  
 
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it is possible to abort a landing after selecting reverse thrust as a last resort if the situation dictates (e.g. another aircraft or vehicle on the runway).
How will you judge whether you will overfly the vehicle or hit it harder? What happens if one reverser doesn't stow?
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Old 13th Sep 2016, 15:03
  #1490 (permalink)  
 
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What happens if one reverser doesn't stow?
The system is designed to make sure the reversers completely stow.
At Cranbrook, the problem was the T/R hadn't finished the stow cycle when the air/ground indication went 'air' - which closed the T/R isolation valve. The aerodynamic forces on the T/R then pushed it back open (clamshell type reverser).
Since Cranbrook, the thrust reverser systems have been designed to keep the isolation valve open until the reverser has completely stowed and locked, and the actuators are sized to insure they can overcome any aerodynamic forces at high engine power.
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Old 13th Sep 2016, 15:15
  #1491 (permalink)  
 
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To all SOP gurus and FMA junkies:

You are most probably right in all your theories, assumptions, and recommendations. What you all forget however, is that we are all human. In very unexpected and thus stressful situations we tend to have a short brain [email protected] and are reduced to a very basic existence and presence as a pilot.

That is when your basic skills should set in, your pilot instincts, your muscle memory or whatever you want to call it.
This will help you through the first ~10 seconds until you get back all your senses.

Many incidents and studies have unfortunately proven --, that the inevitably appearing statements like ‘it was displayed on the FMA’ or that ‘if you had analysed your instruments or indicators’ you would have had a clear picture as to which of the hundreds of magical SOPs or beautiful manoeuvres in the FCOMs would have helped you out of that situation, -- are a cry in the dark.
In moments as described above, our intellectual input receiving capacity is almost zero, the only thing that still works is our tactile input and basic skills and instincts.

Anyone pretending to be able to correctly absorb FMA, CDU and EICAS/ECAM indications at the same time and precision as the PFD indications and engine indicators, when you are confronted with an unusual and unexpected situation, you missed your vocation! You should have applied to Houston!

I admit, i never could. In my 35+ years of airline operation as a pilot, I have witnessed several such difficult situations and it always took me a few seconds to regain my composure and I was almost never able to use any indication in letters or digits, only very basic analogue and pictorial indications.
What helped me out of such situations were those primary, very basic indications and some extremely basic movements on stick and throttle.
Everything else followed a few moments later, they were then very helpful to get back to normal, but never the primary saviours.

But to do so, I am grateful that I was lucky enough to have been allowed a career that enabled me to train and gain experience as to acquire these skills.
I very much doubt that the majority of more recent pilot colleagues were given this opportunity.

That is a huge problem and might be the root cause of many ‘new’ kind of accidents.
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Old 13th Sep 2016, 15:49
  #1492 (permalink)  
 
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An interesting observation that may have been mentioned here already, its a long thread.

I am saddened to see ATC get involved in issuing instructions so early in the GA procedure.

Makes it hard to aviate, navigate then communicate!!!
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Old 13th Sep 2016, 15:53
  #1493 (permalink)  
 
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Bang on Glofish.
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Old 13th Sep 2016, 15:59
  #1494 (permalink)  
 
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notapilot, The objective of my post #1475 was to generate thought about contributing factors, it was not intended to preempt any report. Actually this type of thinking does not require a report, just a trigger to consider safety issues from a range of perspectives, individual, operator, manufacturer, or regulator, irrespective of their involvement in this accident. It would be even more beneficial if we can suppress hindsight bias, avoid using outcome knowledge to infer cause.

Many posts continue to focus on training and procedures; this line of thought still infers blame; the human is broken, fix it, like mending a machine.
The alternative requires industry to reconsider safety thinking. This type of accident isn't caused, it emerges from 'normal' operations; they are surprising events, particularly to management, manufacturers, and regulators, because the overall system did not work as intended - our assumptions about human performance in the context of the man-machine-environment, were incorrect. In effect these types of accident are designed into the system, again, by all of us.

Lonewolf, pitch+power=, yes a classic, but if the context of operation is changed (man-machine-environment) then the value of such fundamentals can also change, even weakened beyond relevance. Does the industry 'know' if pilots look at pitch vs using FDs. Similarly with dependency on auto-thrust, 'power' may not have the same piloting relationship.

C_Twitcher, yes the latent 'factor' may still be lurking; even though we have knowledge of this accident, the risk of a further event is unchanged.
Re RAAS, it's now several hours since posting a RAAS question in Tech Log. Is the absence of replies indicative of the level of system knowledge for a major safety system installed in many aircraft, ... or does limited knowledge generate safety weakness if inappropriately employed.
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Old 13th Sep 2016, 16:12
  #1495 (permalink)  
 
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Globefish & Alf: and others who have commented, not just on this topic, but in general. IMHO it is the case that in some scenarios, especially with large startle factor, SOP's don't always come to your aid. By that I mean this: you as a pilot feel the need to abort a landing. It could be at minima, close to the ground or on the ground. One will have more of a startle factor than another. One will have been briefed more than the other. One will have been practiced more than the other.
If you execute the low startle factor well briefed manoeuvre it is likely to go OK. The SOP's will kick in. You have spare capacity to think and be aware of what's going on. Both of you know & understand the scenario.
Now you end up in one of the other scenarios where you need to think as a basic pilot, but are slowed down by trying to remember the SOP that doesn't seem to quite fit the scenario. It would be easy to jumble up the sequence or forget items. You try, because in the sim you are berated if your don't follow SOP's. Your airmanship brain is confused because you feel the need for discretion, but hesitate and try to spit the correct words out and do the correct actions.
Go back to being a basic pilot. A GA in a Cessna is similar to an all engine a/c; i.e. no rudder necessary. It's power up, speed up, nose up, gear up. The brain can stay clean & clear. It's called KISS.
I wonder if the rigid SOP's have made it difficult, unnecessarily?
I have flown for one airline whose GA SOP call outs & actions make me need to go to RADA for a week. Now transpose them to this scenario. I hate to think.
I've also flown for airlines whose dogma was "the SOP's will keep you safe." Hm???
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Old 13th Sep 2016, 16:23
  #1496 (permalink)  
 
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A nice handy TOGA button that sometimes doesn't work is something to be very wary of.
Indeed. And that is the point of riding or at least following the power levers when the autothrottle is engaged. When you're close to the ground and at low speed, thrust is a critical factor for essentially any maneuver and in my opinion (and the way I was trained) the pilots (both of them) NEVER assume thrust is correct but always verify.

Let me put this in perspective: My multi-engine experience was in P-3s. The P-3 has TWO complete sets of power levers, one set each for the pilot (1P) and the copilot (2P). The flight engineer (FE) sits in a seat facing forward just aft of the center pedestal and has access to BOTH sets of power levers. The arrangement means the P-3 had a "voice activated" autothrottle system. By this I mean that it was routine for the pilot at the controls to call out "horsepower XXXX" to the FE. The pilot at the controls has his hand on the power levers on his side (he "rides" the power levers and can feel what the FE is doing) while the FE uses the power levers on the other side to set the desired power. The pilot not at the control places his hand on the pedestal just behind the levers the FE is operating as back up (he "follows" the power levers). In other words, it was SOP that THREE sets of hands are feeling the advance of the power levers, and at least two sets of eyes are checking the torquemeter gauge to verify that power is what it should be.

For me, one pilot riding the power levers while the other is following the power levers while the autothrottle (either flesh and blood or electronic) is engaged is instinctive. Thus it is unfathomable to me that the pilots in this incident were not aware that the autothrottle system for whatever reason was not advancing the power levers, whether that was by design, due to system failure, or due to leprechauns dancing on the center pedestal. But this is because of the training I received and the SOP we followed. To me, it is clear that the training these pilots received and the SOP they were required to follow set them up for failure. And to me, that's very sad. And since managers are involved, I must wonder how long it will take to correct this clear deficiency in training and SOP.

Last edited by KenV; 13th Sep 2016 at 16:33.
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Old 13th Sep 2016, 16:38
  #1497 (permalink)  
 
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Anyone who isn't an "FMA junkie" has no place whatsoever in the cockpit of a modern jet.

It really IS that simple I'm afraid.

Not saying other things aren't important too.
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Old 13th Sep 2016, 16:50
  #1498 (permalink)  
 
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Since Cranbrook, the thrust reverser systems have been designed to keep the isolation valve open until the reverser has completely stowed and locked, and the actuators are sized to insure they can overcome any aerodynamic forces at high engine power.
td, this is not entirely correct, as the loss of Lauda Air Flight 004 (the first 767 loss) sadly proved. That was the seminal event that resulted in a truly fail-safe thrust reverser design.
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Old 13th Sep 2016, 17:15
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It is reasonably clear that Boeing recommended go around procedure after touch down was not followed where pilot needs to apply TOGA manually and initiate climb without FDs. why wasn't it done? Man, machine, environment. It could be one time error, inadequate training of this particular situation or lack of required knowledge of automation. Machine, GA mode could be improved. Environment? high temperature, moderate wind shear, demanding but not so hostile.We have to wait for full report.
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Old 13th Sep 2016, 17:25
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The system is designed to make sure the reversers completely stow.
How come airbus doesn't agree with that? After all airbus doesn't manufacture engines. reverse is full stop for airbus.
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