Pax sue Boeing in DBX crash
Never thought it dangerous even once
The post from our US MIL C5 colleague above says it all!
Originally Posted by PEI_3721 View Post
Fix the system (technical and organisational), not the pilot.
Why not both?
Fix the system (technical and organisational), not the pilot.
Why not both?
With all the discussion about TOGA (or not TOGA), another aspect of this crash (or hole in the cheese, if you like) seems to have been lost to view: the crew selected "gear up" as soon as go-around was called, less than 85 feet off the ground and before confirming positive rate of climb. As I understand it, even with the mix-up over TOGA, if the gear had been down when they sank back onto the runway then although they might have gone off the end, the final crash would have been much less serious.
Controversial, moi?
Thus, for us older pilots, a physical sensation, and tactile action, of GA has been removed. I appreciate that pilots who've flown only FBW will not miss anything, but I wonder if removing all these various sensations is in fact an improvement.
Pilot mishandling for sure but another side of the coin.
Vessbot, #136, "why not both" - system and pilot.
A glib response would be because you can never be sure that you have fixed the pilot, every single one, and for all of the situations that you can imagine.
Thus concentrate on the system, its never perfect because that also involves the human, but you should be able to improve previous efforts - learn and amend. And do not forget to place your trust in pilots because sometime they may be able to deal with those situations which management are unable to imagine.
‘You fix what you find; you find what you look for”. This crux of the point is that if you first focus on the pilot then the safety efforts may not progress any further.
Start with the system, this will involve humans; focus on how the system might help the pilots function - to do the day job, and not the other way round.
‘Fixing’ pilots in this incident (there were ‘fired’?) will not help the next crew faced with this or a similar dilemma.
A glib response would be because you can never be sure that you have fixed the pilot, every single one, and for all of the situations that you can imagine.
Thus concentrate on the system, its never perfect because that also involves the human, but you should be able to improve previous efforts - learn and amend. And do not forget to place your trust in pilots because sometime they may be able to deal with those situations which management are unable to imagine.
‘You fix what you find; you find what you look for”. This crux of the point is that if you first focus on the pilot then the safety efforts may not progress any further.
Start with the system, this will involve humans; focus on how the system might help the pilots function - to do the day job, and not the other way round.
‘Fixing’ pilots in this incident (there were ‘fired’?) will not help the next crew faced with this or a similar dilemma.
OldLurker, 
the crew selected gear up …
Historically GAs have been trained as requiring urgent action. Way back in the distant past a critical issue was obstacle clearance for the GA flight path with engine failure. Nowadays with power excess, improved engine reliability, this is not a significant concern, indeed the regulators are focusing on all aircraft having automated reduced thrust for a GA (yet still require on pilots to select higher when required - but how might they know, I digress).
The aerodynamics of a GA are no different than for landing, except with added thrust you reach a point when the aircraft will not land; add more thrust it begins to climb. This is like a takeoff, retract flaps to improve ‘takeoff’ performance, retract the gear in the same way as for take off, no rush, minimise the opportunity for mistakes, …
The problem is founded in history, it is exacerbated by todays lack of joined up thinking between certification requirement, training regulations, safety management, and human factors; regulatory authorities cover all of these areas, but are they in ‘ivory towers’ (without windows).
the crew selected gear up …Historically GAs have been trained as requiring urgent action. Way back in the distant past a critical issue was obstacle clearance for the GA flight path with engine failure. Nowadays with power excess, improved engine reliability, this is not a significant concern, indeed the regulators are focusing on all aircraft having automated reduced thrust for a GA (yet still require on pilots to select higher when required - but how might they know, I digress).
The aerodynamics of a GA are no different than for landing, except with added thrust you reach a point when the aircraft will not land; add more thrust it begins to climb. This is like a takeoff, retract flaps to improve ‘takeoff’ performance, retract the gear in the same way as for take off, no rush, minimise the opportunity for mistakes, …
The problem is founded in history, it is exacerbated by todays lack of joined up thinking between certification requirement, training regulations, safety management, and human factors; regulatory authorities cover all of these areas, but are they in ‘ivory towers’ (without windows).
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Tools, and their evolution in our modern world e.g. FBW. There have been any wonderful improvements made via technical advances. I wonder if there are some that have, subtly, been less perfect.
In underslung engined basic control a/c you increase umph and the nose rises. You feel this in your backside as well as see it outside or on the PFD. Your stretch your arm and your body gives some feedback that thrust has been applied. This happens without having to apply back elevator. That is done to expedite the change in V/S from -ve to +ve.
There is also the large trim change, usually from nose up on approach to having to take some off during the rotation to GA attitude. This elevator force, plus your backside, inform your senses that thrust has increased. If I understand correctly FBW removes this trim change. Thus, for us older pilots, a physical sensation, and tactile action, of GA has been removed. I appreciate that pilots who've flown only FBW will not miss anything, but I wonder if removing all these various sensations is in fact an improvement. The debate about non-moving thrust levers on AB has been beaten to death with no firm conclusion. Those against that philosophy thought that allowing thrust to change with out any tactile indication, or trim change on the elevator, isolated PF a little from what was going on.
I've never flown FBW or manual approaches with A/T. It disturbed me, and caused a comment, when I watched F/O's as PF on autolands, not follow through on the controls all the way down. On choppy days it was reassuring to feel the control column and A/T doing their thing, and then feel the nose up trim come in <500'. It connected you to the machine. Even more important if it was only a CAT 1 ILS to man land. You were more in tune with the machine and the elements. I wonder if FBW, where it seems you just point the a/c where you want it to go and auto-trim & auto-throttle take care of everything else, is the B's & E's it's all cracked up to be?
Those who've made the transition will have helpful educational comments, I'm sure.
In underslung engined basic control a/c you increase umph and the nose rises. You feel this in your backside as well as see it outside or on the PFD. Your stretch your arm and your body gives some feedback that thrust has been applied. This happens without having to apply back elevator. That is done to expedite the change in V/S from -ve to +ve.
There is also the large trim change, usually from nose up on approach to having to take some off during the rotation to GA attitude. This elevator force, plus your backside, inform your senses that thrust has increased. If I understand correctly FBW removes this trim change. Thus, for us older pilots, a physical sensation, and tactile action, of GA has been removed. I appreciate that pilots who've flown only FBW will not miss anything, but I wonder if removing all these various sensations is in fact an improvement. The debate about non-moving thrust levers on AB has been beaten to death with no firm conclusion. Those against that philosophy thought that allowing thrust to change with out any tactile indication, or trim change on the elevator, isolated PF a little from what was going on.
I've never flown FBW or manual approaches with A/T. It disturbed me, and caused a comment, when I watched F/O's as PF on autolands, not follow through on the controls all the way down. On choppy days it was reassuring to feel the control column and A/T doing their thing, and then feel the nose up trim come in <500'. It connected you to the machine. Even more important if it was only a CAT 1 ILS to man land. You were more in tune with the machine and the elements. I wonder if FBW, where it seems you just point the a/c where you want it to go and auto-trim & auto-throttle take care of everything else, is the B's & E's it's all cracked up to be?
Those who've made the transition will have helpful educational comments, I'm sure.
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And a successful landing is only the result of an approach that didn't end as a go around. Plan for and be prepared for a go around up to the point that reverse thrust is selected has to be the only way a professional aviator approaches the job!
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And a successful landing is only the result of an approach that didn't end as a go around. Plan for and be prepared for a go around up to the point that reverse thrust is selected has to be the only way a professional aviator approaches the job!
Indeed. An RTO or a GA should never be a surprise.
Indeed. An RTO or a GA should never be a surprise.
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The GA button is part of the thrust lever assembly, is a just ahead and slightly underneath the highest point of the levers. You don't take your hand off the levers to use it. Old fashioned gits like me hit the switch and follow the levers forwards to make sure the thing has worked. As you press the button, you call "Go around..." to put your colleague in "go around mode" you pitch up and carry on flying. If you are lucky, your well rehearsed go around procedure then takes place as the pilot monitoring looks for go around power, a positive rate and an appropriate airspeed.
The announciation is not important. The thrust, positive climb rate and appropriate airspeed are. At about 400' the lack of go around guidance, lateral and/or vertical will probably be noticed and then alternative steps will be taken to ensure an appropriate flight path. After landing, you call your technical support people and ask about what just happened. Then the learning starts.
You will find that lots of modes and buttons do not work as advertised. Sometimes you get a message or a ping, sometimes you don't. What is important is that you carry a mental model of what you would like to happen before you need it. Then when you are let down you use another method to get what you want. Saying the button didn't work as advertised when alternative means were available but not used is not really acceptable.
The announciation is not important. The thrust, positive climb rate and appropriate airspeed are. At about 400' the lack of go around guidance, lateral and/or vertical will probably be noticed and then alternative steps will be taken to ensure an appropriate flight path. After landing, you call your technical support people and ask about what just happened. Then the learning starts.
You will find that lots of modes and buttons do not work as advertised. Sometimes you get a message or a ping, sometimes you don't. What is important is that you carry a mental model of what you would like to happen before you need it. Then when you are let down you use another method to get what you want. Saying the button didn't work as advertised when alternative means were available but not used is not really acceptable.
The GA button is part of the thrust lever assembly, is a just ahead and slightly underneath the highest point of the levers. You don't take your hand off the levers to use it. Old fashioned gits like me hit the switch and follow the levers forwards to make sure the thing has worked. As you press the button, you call "Go around..." to put your colleague in "go around mode" you pitch up and carry on flying. If you are lucky, your well rehearsed go around procedure then takes place as the pilot monitoring looks for go around power, a positive rate and an appropriate airspeed.
The announciation is not important. The thrust, positive climb rate and appropriate airspeed are. At about 400' the lack of go around guidance, lateral and/or vertical will probably be noticed and then alternative steps will be taken to ensure an appropriate flight path. After landing, you call your technical support people and ask about what just happened. Then the learning starts.
You will find that lots of modes and buttons do not work as advertised. Sometimes you get a message or a ping, sometimes you don't. What is important is that you carry a mental model of what you would like to happen before you need it. Then when you are let down you use another method to get what you want. Saying the button didn't work as advertised when alternative means were available but not used is not really acceptable.
The announciation is not important. The thrust, positive climb rate and appropriate airspeed are. At about 400' the lack of go around guidance, lateral and/or vertical will probably be noticed and then alternative steps will be taken to ensure an appropriate flight path. After landing, you call your technical support people and ask about what just happened. Then the learning starts.
You will find that lots of modes and buttons do not work as advertised. Sometimes you get a message or a ping, sometimes you don't. What is important is that you carry a mental model of what you would like to happen before you need it. Then when you are let down you use another method to get what you want. Saying the button didn't work as advertised when alternative means were available but not used is not really acceptable.
I never disputed that the crew failed, or that the overwhelming majority of crews would not fail.
Nevertheless, the crew did actually command thrust.
The aircraft did actually silently ignore that command.
Do you believe that the automatics had a better view of the suitability of the commanded thrust level than the crew did?
I think the result says no, and on this edge the automatics has a fault in it.
Perhaps this isn't the most brilliant example.
However, there is a limit to the acceptable sum total of "modes and buttons that do not work as advertised".
Even assuming this case fails, I see no harm in court cases like this playing a role in establishing where that limit lies.
Last edited by pilot9249; 25th Aug 2017 at 23:11.
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You push the TOGA buttons to bring the flight directors into Go Around mode, and you shove the thrust levers forwards, and perhaps the autothrottle will assist, maybe not, and you're away.
Simples really.
The A/T has a habit of failing, and is indeed inhibited in a touch and go scenario, so good airmanship dictates you manually apply thrust as well.
If you tap the toga buttons then place your hand back on the control column then you are an utter idiot who has no place in the flight deck. Definitely not mine.
But who does 'airmanship' any more these days? Certainly not muppets like this coming up through the ranks.
Good grief, give me strength.
Simples really.
The A/T has a habit of failing, and is indeed inhibited in a touch and go scenario, so good airmanship dictates you manually apply thrust as well.
If you tap the toga buttons then place your hand back on the control column then you are an utter idiot who has no place in the flight deck. Definitely not mine.
But who does 'airmanship' any more these days? Certainly not muppets like this coming up through the ranks.
Good grief, give me strength.
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spt - You totally miss the reality. This crew DID NOT, EVER command go-around thrust. The PF just pressed a button. The thrust levers, the things that actually command thrust did not move forwards until just two seconds before impact. There was also no indication of any increase of thrust. This is very basic stuff. A home analogy would be where a tap in your bathroom doesn't turn off when you turn it off. Do you let your house flood and sue the tap manufacturer? No. You turn off the tap isolator. Later, at a time of you convenience you replace the ceramic shut off valve in your still dry house. If that doesn't work you turn off the mains and open every other tap in the house to reduce the impact of the recalcitrant tap. You then install an isolator and replace the valve. When we first learn to fly we are taught the aeronautical equivalents of these fixes. This is basic, basic stuff taught from Day 1 and certainly re-inforced every time we go to the sim.
If my aircraft doesn't automatically give me take off power (and it will not if certain criteria are met) then I make sure it bloody well will. If the gear doesn't come up and I need it up, it will (subject to certain criteria) come up, if I need more thrust than permitted, I will have it. My colleagues and I have had many, many training sessions battling with usual, unusual and unexpected mode failures dreamed up by the psychos in the training department. The deal is always the same. You are flying and you are in charge. If things don't work as advertised is not important and certainly not a big issue. You are still in charge and there is a very, very simple way out that you have to take. No ifs, no buts.
Yes, a court case might be the best place to test this and I do hope common sense prevails. And if I was Boeing I would drag this out until it hurts the opposition. Anything to stop the greedy and ignorant from initiating cases without merit.
PM
If my aircraft doesn't automatically give me take off power (and it will not if certain criteria are met) then I make sure it bloody well will. If the gear doesn't come up and I need it up, it will (subject to certain criteria) come up, if I need more thrust than permitted, I will have it. My colleagues and I have had many, many training sessions battling with usual, unusual and unexpected mode failures dreamed up by the psychos in the training department. The deal is always the same. You are flying and you are in charge. If things don't work as advertised is not important and certainly not a big issue. You are still in charge and there is a very, very simple way out that you have to take. No ifs, no buts.
Yes, a court case might be the best place to test this and I do hope common sense prevails. And if I was Boeing I would drag this out until it hurts the opposition. Anything to stop the greedy and ignorant from initiating cases without merit.
PM
Last edited by Piltdown Man; 26th Aug 2017 at 22:12. Reason: Change of an "any" to "of"
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spt - You totally miss the reality. This crew DID NOT, EVER command go-around thrust. The PF just pressed a button. The thrust levers, the things that actually command thrust did not move forwards until just two seconds before impact. There was also no indication of any increase any thrust. This is very basic stuff. A home analogy would be where a tap in your bathroom doesn't turn off when you turn it off. Do you let your house flood and sue the tap manufacturer? No. You turn off the tap isolator. Later, at a time of you convenience you replace the ceramic shut off valve in your still dry house. If that doesn't work you turn off the mains and open every other tap in the house to reduce the impact of the recalcitrant tap. You then install an isolator and replace the valve. When we first learn to fly we are taught the aeronautical equivalents of these fixes. This is basic, basic stuff taught from Day 1 and certainly re-inforced every time we go to the sim.
If my aircraft doesn't automatically give me take off power (and it will not if certain criteria are met) then I make sure it bloody well will. If the gear doesn't come up and I need it up, it will (subject to certain criteria) come up, if I need more thrust than permitted, I will have it. My colleagues and I have had many, many training sessions battling with usual, unusual and unexpected mode failures dreamed up by the psychos in the training department. The deal is always the same. You are flying and you are in charge. If things don't work as advertised is not important and certainly not a big issue. You are still in charge and there is a very, very simple way out that you have to take. No ifs, no buts.
Yes, a court case might be the best place to test this and I do hope common sense prevails. And if I was Boeing I would drag this out until it hurts the opposition. Anything to stop the greedy and ignorant from initiating cases without merit.
PM
If my aircraft doesn't automatically give me take off power (and it will not if certain criteria are met) then I make sure it bloody well will. If the gear doesn't come up and I need it up, it will (subject to certain criteria) come up, if I need more thrust than permitted, I will have it. My colleagues and I have had many, many training sessions battling with usual, unusual and unexpected mode failures dreamed up by the psychos in the training department. The deal is always the same. You are flying and you are in charge. If things don't work as advertised is not important and certainly not a big issue. You are still in charge and there is a very, very simple way out that you have to take. No ifs, no buts.
Yes, a court case might be the best place to test this and I do hope common sense prevails. And if I was Boeing I would drag this out until it hurts the opposition. Anything to stop the greedy and ignorant from initiating cases without merit.
PM
No doubt the court case will focus on whether pressing TOGA at 100 knots was a clear and unambigous command for thrust.
Or whether the crew pressed it inappropriately because of a leaky tap.
Let's see what happens.
Last edited by pilot9249; 26th Aug 2017 at 03:10.
Piltdown Man, I think that you are missing a bit of reality.
Did these guys practice, in the Sim, startle touch and goes?
That's bordering on the ridiculous. It's stupid that TOGA isn't available at 130kts after touchdown. Yes yes yes you don't want it available on the blocks after start but there are plenty of other system (antiskid, for example) that don't work depending on the speed). Just like it is stupid for an autothrottle to stay asleep on final with the speed at Ref-20. Ideological nonsense.
These guys got set up by the system (design and regulatory), far and square. Sure, they stuffed it, but they are not solely to blame.
My colleagues and I have had many, many training sessions battling with usual, unusual and unexpected mode failures dreamed up by the psychos in the training department.
And if I was Boeing I would drag this out until it hurts the opposition.
These guys got set up by the system (design and regulatory), far and square. Sure, they stuffed it, but they are not solely to blame.
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Ask yourself the following two questions: Which of the two possibilities would likely prevent another DXB / SFO autothrottle type accident:
1) System enhancement by Boeing of the autothrottle to account for known design issues.
2) Successful defence in court by Boeing of the current autothrottle system design.
Second question, which of these two outcomes would likely reduce the likely probability of future similar event, ie which would be the best safety outcome?
1) System enhancement by Boeing of the autothrottle to account for known design issues.
2) Successful defence in court by Boeing of the current autothrottle system design.
Second question, which of these two outcomes would likely reduce the likely probability of future similar event, ie which would be the best safety outcome?
Bloggs
So, Boeing keeps TOGA active after touchdown. Some pilot inadvertently commands TOGA after landing, the aircraft goes off the runway. There would be a 50 page thread here discussing how stupid it is that Boeing didn't inhibit TOGA after landing.
As a designer, you simply cannot protect against every inadvertent switch or button push. If you want to claim no pilot would ever inadvertently push TOGA after touchdown, I can provide a list as long as my arm of cases of pilots who have inadvertently actuated flight deck switches, including shutting down engines (or the wrong engine) - and two cases where the pilot shut down BOTH engines at less than 3,000 ft. during takeoff.
As a designer, we also have to be extremely sensitive to 'unintended consequences' where you change the design to address one failure mode, and create a new failure mode that is even worse. A very unpleasant example is the 'fix' for the Cranbrook 737 crash (https://en.wikipedia.org/wiki/Pacifi...nes_Flight_314), where they rejected the landing after the T/Rs were deployed, one reverser didn't completely stow and lock prior to liftoff. The aircraft design removed hydraulics from the reverser in 'air' mode and the aero forces redeployed the reverser at low altitude. The 'fix' - auto-restow -was ultimately responsible for an even worse crash - Lauda 767 (https://en.wikipedia.org/wiki/Lauda_Air_Flight_004) when it allowed hydraulics to the T/R in-flight...
So, Boeing keeps TOGA active after touchdown. Some pilot inadvertently commands TOGA after landing, the aircraft goes off the runway. There would be a 50 page thread here discussing how stupid it is that Boeing didn't inhibit TOGA after landing.
As a designer, you simply cannot protect against every inadvertent switch or button push. If you want to claim no pilot would ever inadvertently push TOGA after touchdown, I can provide a list as long as my arm of cases of pilots who have inadvertently actuated flight deck switches, including shutting down engines (or the wrong engine) - and two cases where the pilot shut down BOTH engines at less than 3,000 ft. during takeoff.
As a designer, we also have to be extremely sensitive to 'unintended consequences' where you change the design to address one failure mode, and create a new failure mode that is even worse. A very unpleasant example is the 'fix' for the Cranbrook 737 crash (https://en.wikipedia.org/wiki/Pacifi...nes_Flight_314), where they rejected the landing after the T/Rs were deployed, one reverser didn't completely stow and lock prior to liftoff. The aircraft design removed hydraulics from the reverser in 'air' mode and the aero forces redeployed the reverser at low altitude. The 'fix' - auto-restow -was ultimately responsible for an even worse crash - Lauda 767 (https://en.wikipedia.org/wiki/Lauda_Air_Flight_004) when it allowed hydraulics to the T/R in-flight...
Bloggs,
What's a "startle touch and go"? Touch and goes are planned maneuvers, I thought. The crew was apparently doing a go around. Should the T7 or any plane have a A/T touch and go mode. They were trained in go arounds, presumably, and both pilots messed it up, full stop. Are we now saying pilots are startled by a go around?
BTW, the EK SOP on "long landing" is a system error. They employ pilots to make landings which require judgement inherent in being a pilot.
GF
What's a "startle touch and go"? Touch and goes are planned maneuvers, I thought. The crew was apparently doing a go around. Should the T7 or any plane have a A/T touch and go mode. They were trained in go arounds, presumably, and both pilots messed it up, full stop. Are we now saying pilots are startled by a go around?
BTW, the EK SOP on "long landing" is a system error. They employ pilots to make landings which require judgement inherent in being a pilot.
GF
Pushing a button is meaningless until you see proof that the commanded action is actually occurring. Even pushing throttles up is merely a command until you see/feel/hear evidence that thrust is actually increasing. It is not acceptable for a pilot to trust any system unconditionally. Each commanded action must then be monitored to the extent necessary to verify execution, then that the desired result is achieved.
Think of like this: Button pushes are mere rumors until actual results are observed to occur! It's a crying shame that any pilot would actually place their passengers and their own safety in the hands of a mere rumor...
So follow the A/T with the hand if they move, and verify engine acceleration by instrument indications/human senses whether they move or not. Just because one thinks they remember having ordered another scotch doesn't necessarily mean it's been served and consumed. That feeling in the throat will be a better indicator!
Think of like this: Button pushes are mere rumors until actual results are observed to occur! It's a crying shame that any pilot would actually place their passengers and their own safety in the hands of a mere rumor...
So follow the A/T with the hand if they move, and verify engine acceleration by instrument indications/human senses whether they move or not. Just because one thinks they remember having ordered another scotch doesn't necessarily mean it's been served and consumed. That feeling in the throat will be a better indicator!
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Ask yourself the following two questions: Which of the two possibilities would likely prevent another DXB / SFO autothrottle type accident:
1) System enhancement by Boeing of the autothrottle to account for known design issues.
2) Successful defence in court by Boeing of the current autothrottle system design.
3) Train pilots correctly!!
So follow the A/T with the hand if they move, and verify engine acceleration by instrument indications/human senses whether they move or not. Just because one thinks they remember having ordered another scotch doesn't necessarily mean it's been served and consumed. That feeling in the throat will be a better indicator!
LoL: mine's a double just to make sure.
Pushing a button is meaningless until you see proof that the commanded action is actually occurring. Each commanded action must then be monitored to the extent necessary to verify execution.
Spot ON. Remember the Air Kenya B737 crash at night where they spiralled to the ground after takeoff. The captain thought he had engaged the autopilot and then directed his attention to Wx avoidance while the a/c slowly rolled into a spiral. They did not get the A/P disconnect warning wailer; I can't remember if they got CWS. Either way the button push did not have the desired effect and they did not check/confirm and died. I don't remember a great out-pouring of wrath that Boeing should have designed it such that the A/P disconnect wailer should have sounded with the failure to connect. That indeed could have been a good idea.
In the DXB case if there had been an A/T disconnect siren when it failed to connect?????? but there isn't such an alert even during a normal disconnect. Should there be? Disconnects are normally a manual action, but any electronic system can go AWOL. Should they all have audible warnings? Not only for disconnect, but also for failure to connect? The list would never end. The design philosophy must have been that visual alerting is enough as that is what pilots are supposed to do, monitor and confirm, and should be trained to do so. A symphony of differing audios is not the best way. If it was a voice saying "auto-throttle disconnect" perhaps that might work. Remember the B737 confusion between the audio take-off config warning & cabin altitude warning. The fix was a visual addition to solve the confusion. OK, B737 doesn't have voice alerts, (except EGPWS) but it is known that they are more affective (except to certain Spanish speaking DC-10 pilots)
But we are back again to training and individual standards. That conclusion keeps cropping up in many occurrences. People keep saying that technology has made flying safety with less crashes per.........etc. However, I'd guess that in decades before there were more crashes due to malfunctions in the aviation system, and then human mis-actions, than direct simple screw ups. There have also been many instances where technology screwed up and the human went back to basics to compensate and avert disaster. The human, and there are many links in the chain, has always been identified as the weakest link. Technology has been used to try and solve this problem, and to some degree succeeded, and still does.
It is deeply worrying that in the past decade there have been quite a few perfectly serviceable a/c that have speared in due to the crew not understanding this supposedly life saving technology, mismanaging it, or not being able to compensate for its malfunction. The back to basics approach was not available or not applied.
1) System enhancement by Boeing of the autothrottle to account for known design issues.
2) Successful defence in court by Boeing of the current autothrottle system design.
3) Train pilots correctly!!
So follow the A/T with the hand if they move, and verify engine acceleration by instrument indications/human senses whether they move or not. Just because one thinks they remember having ordered another scotch doesn't necessarily mean it's been served and consumed. That feeling in the throat will be a better indicator!
LoL: mine's a double just to make sure.
Pushing a button is meaningless until you see proof that the commanded action is actually occurring. Each commanded action must then be monitored to the extent necessary to verify execution.
Spot ON. Remember the Air Kenya B737 crash at night where they spiralled to the ground after takeoff. The captain thought he had engaged the autopilot and then directed his attention to Wx avoidance while the a/c slowly rolled into a spiral. They did not get the A/P disconnect warning wailer; I can't remember if they got CWS. Either way the button push did not have the desired effect and they did not check/confirm and died. I don't remember a great out-pouring of wrath that Boeing should have designed it such that the A/P disconnect wailer should have sounded with the failure to connect. That indeed could have been a good idea.
In the DXB case if there had been an A/T disconnect siren when it failed to connect?????? but there isn't such an alert even during a normal disconnect. Should there be? Disconnects are normally a manual action, but any electronic system can go AWOL. Should they all have audible warnings? Not only for disconnect, but also for failure to connect? The list would never end. The design philosophy must have been that visual alerting is enough as that is what pilots are supposed to do, monitor and confirm, and should be trained to do so. A symphony of differing audios is not the best way. If it was a voice saying "auto-throttle disconnect" perhaps that might work. Remember the B737 confusion between the audio take-off config warning & cabin altitude warning. The fix was a visual addition to solve the confusion. OK, B737 doesn't have voice alerts, (except EGPWS) but it is known that they are more affective (except to certain Spanish speaking DC-10 pilots)
But we are back again to training and individual standards. That conclusion keeps cropping up in many occurrences. People keep saying that technology has made flying safety with less crashes per.........etc. However, I'd guess that in decades before there were more crashes due to malfunctions in the aviation system, and then human mis-actions, than direct simple screw ups. There have also been many instances where technology screwed up and the human went back to basics to compensate and avert disaster. The human, and there are many links in the chain, has always been identified as the weakest link. Technology has been used to try and solve this problem, and to some degree succeeded, and still does.
It is deeply worrying that in the past decade there have been quite a few perfectly serviceable a/c that have speared in due to the crew not understanding this supposedly life saving technology, mismanaging it, or not being able to compensate for its malfunction. The back to basics approach was not available or not applied.
Last edited by RAT 5; 26th Aug 2017 at 08:34.
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Capn Bloggs - I'm totally with you. I'll bet this crew had never practiced this manoeuvre. Furthermore, I'm not so sure that their company's attitude to safety is entirely commensurate with aviation in the 21st century. I know a few people there and find some of what they tell me quite alarming. Like their charming "Final Written Warning" letters, unpleasant chats with those in the office, behind the scenes "heads-up" for check pilots just before sim sessions and their corrosive reporting culture where one colleague drops another in the mooh.
And no, I don't necessarily want TOGA button availability on landing roll. As long as the thrust levers move and the engines spool up I'll do the rest.
Boeing's job is to design and document how their products are built. It is the user's task to take the finished product and design a training programme around their pilots and the aircraft so that most foreseeable eventualities will have been covered to an acceptable standard. It is also the user's task to ensure that a sufficiently flexible set of SOP's are designed so that pilots can continue to hone their flying skills during normal operations. Rigid, "one size fits all" SOPS result in crews losing their ability to think and their flying skills being eroded.
I totally agree.
PM
And no, I don't necessarily want TOGA button availability on landing roll. As long as the thrust levers move and the engines spool up I'll do the rest.
Boeing's job is to design and document how their products are built. It is the user's task to take the finished product and design a training programme around their pilots and the aircraft so that most foreseeable eventualities will have been covered to an acceptable standard. It is also the user's task to ensure that a sufficiently flexible set of SOP's are designed so that pilots can continue to hone their flying skills during normal operations. Rigid, "one size fits all" SOPS result in crews losing their ability to think and their flying skills being eroded.
These guys got set up by the system (design and regulatory), far (sic) and square. Sure, they stuffed it, but they are not solely to blame.
PM
Controversial, moi?
In the DXB case if there had been an A/T disconnect siren when it failed to connect?????? but there isn't such an alert even during a normal disconnect.
In normal use of the AT there is an audible and visual (EICAS) warning of disconnect.