Flybe AP has a 'Plummet' Mode?
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Interesting...learning has occurred. Then I echo Fursty Ferret's question.
Taking off with 0000 in the window should really not happen, and taking off with the FD in ALT mode instead of GA should not happen, and engaging the autopilot while climbing out with the FD commanding full nose down and ALT hold displayed should not happen, and waiting till you get to 4000+ FPM descent and GPWS before you disconnect should not happen.
There were way too many pointers something was wrong and none were noticed.
I definitely agree with our company policy of resetting to zero, yes, this wouldn't have happened if they had left the last altitude in but they would most likely have ended up at the wrong altitude, and the amount of things that went wrong here makes not setting the altitude the smallest error in the whole debacle.
"Mildly" Eccentric Stardriver
"The first sector was uneventful, and the aircraft landed on Runway 22 at Belfast City. While it taxied clear of the runway, the co-pilot carried out the ‘after-landing’ checks which included setting the autopilot selected altitude to zero."
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Avherald also says the crew were reading a checklist at 1300 and were not actively paying attention to the monitoring of the flight. In our company you can do it either above MSA or 3000ft whichever is higher. MSA in Belfast City is between 2900 to the north and 3800 to south. Both pilots should have full attention on flying the aircraft below that point, what are you doing with a checklist in your hand just 1000 feet after departure is beyond me
Last edited by Martin_123; 9th Nov 2018 at 17:19.
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ALT SEL is a big Dash gotcha for one, along with the the daft things like pressing the system page selector twice to get stuff onto the right screen, not setting the two remaining V speeds on the other side during the set up etc. It’s all smacks of it being a bit rushed during the design stages.
It has a lot of go though, fair play to Bombardier and P&W, they got that bit right.
It has a lot of go though, fair play to Bombardier and P&W, they got that bit right.
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ALT SEL is a big Dash gotcha for one, along with the the daft things like pressing the system page selector twice to get stuff onto the right screen, not setting the two remaining V speeds on the other side during the set up etc. It’s all smacks of it being a bit rushed during the design stages.
There is a very good reason why the speed bugs work the way they do, it allows for flexibility in airline SOPs
Can you elaborate what is the right screen that you get to see when pressing the sys button twice? I rather prefer hitting buttons twice on the ground to get to the page I want to see on the ground and only press it once in the air when I'm in the emergency, rather to do it the other way around.. Again, can I ask how many hours you have on the Q400 and what was your previous type? maybe habitation is causing some issues with you?
"Mildly" Eccentric Stardriver
Hans. I see your point, but I have to disagree. Surely, setting the CLEARED ALTITUDE is part of the SET and CROSSCHECK. Sure, one pilot can miss it, but two?
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The answer is really simple ... Routine + the fact the brain is really good to see what he want to see ...
How many accident / incident are due because people after doing the same check and SOP for few years, finally got a day : they think they did it, they looked at what to check, they did the call accordign to SOP but in fact they didn't see the selection / switch position ... was wrong.
You really need to force you to do the check and even we are all Human.
I remember in the SIM few years ago, after a go around, I did the check list, I had a look to the no light of the landing geea and happily called "gear up, light out", during the radar vextov I thought the plane was noisy but it didn't trigger anything in my mind, when PF called for gear down during the funal, I realized the gear was already down with 3 green, I then apologize, the captain and the trainer realised at that time the gear were down all the approach, 3 people in a sim ...
Now I agree with many of you, was a lot of possibility to catch the problems sooner ... When they did the taxi check list, was a check of the AP mode, when they lined up, was again a check of the AP mode engaged, I m sure they did the right call and I m sure when investigator asked the crew, they both remember all was fine and set as they called with GA mode engaged (plane was in alt mode on the ground)
How many accident / incident are due because people after doing the same check and SOP for few years, finally got a day : they think they did it, they looked at what to check, they did the call accordign to SOP but in fact they didn't see the selection / switch position ... was wrong.
You really need to force you to do the check and even we are all Human.
I remember in the SIM few years ago, after a go around, I did the check list, I had a look to the no light of the landing geea and happily called "gear up, light out", during the radar vextov I thought the plane was noisy but it didn't trigger anything in my mind, when PF called for gear down during the funal, I realized the gear was already down with 3 green, I then apologize, the captain and the trainer realised at that time the gear were down all the approach, 3 people in a sim ...
Now I agree with many of you, was a lot of possibility to catch the problems sooner ... When they did the taxi check list, was a check of the AP mode, when they lined up, was again a check of the AP mode engaged, I m sure they did the right call and I m sure when investigator asked the crew, they both remember all was fine and set as they called with GA mode engaged (plane was in alt mode on the ground)
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What kind of dash 8 do you fly ? The NG ? Did the alt sel drop out if you touch the cobtcon wheel of autopilot while in alt* ?
I can guarantee you, if you press altsel with 0ft selected and the plane altitude near zero, plane will go to alt locked ...
I can guarantee you, if you press altsel with 0ft selected and the plane altitude near zero, plane will go to alt locked ...
Martin to clarify, you can arm ALT SEL below 1000ft. We regularly set 500ft ALT SEL on visual approaches as an SOP. But in this case it would not arm ALT SEL but go straight to ALT HOLD as the aircraft was already at it's armed altitude.
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Ok, i see the confusion.
In your airline you select the SID alt minus 100ft then press GA, HDG and alt sel.
in flybe, the alt is set to zero, clearance is taken then the PF should set the SID altitude, then press GA, hdg and alt set then calling it, PM should check it.
what they did was, they took clearance, then went straight to press GA, HDG, Alt sel then set the SID altitude, so when alt sel with the altitude selector at 0 was pressed, plane went in alt locked mode.
Then now have a FMA saying HDG and alt locked with the altitude selector set at the SID. So you won't have any alt warning and altitude amber ...
Ofc, the FD was showing a horizontal bat at zero pithc in the ground and not +8 degree with GA mode, thet could have spotted it on the taxi checklist and they could have spotted it on the line up check list (check list ask to call FMA mode), was no alt sel arm white at all so it could have been spotted ... then when passing acceleration altitude, they could have seen the FD showing a deep descent and could have spot it there ... We end up about brain is good to see what is used to see and disregard what doesn't fit in his idea of reality.
How you explain the Emirates 777 with 3 crew trying to do a go around with idle ? They were used to have go around power set by autothrottle ... Expect in that case autothrottle was off due to the plane touching rwy...
Or how explain the airbus A320 in "mont Saint Odile" in France, instead of FPA 3degree they selected VS 3000ft/MN, they then we're focused of why the plane was speeding up ? I do remenrem one of the crew convincing himself saying, oh we have little bit of tail wing and plane really light today .... Brain see what he want to see ...
In your airline you select the SID alt minus 100ft then press GA, HDG and alt sel.
in flybe, the alt is set to zero, clearance is taken then the PF should set the SID altitude, then press GA, hdg and alt set then calling it, PM should check it.
what they did was, they took clearance, then went straight to press GA, HDG, Alt sel then set the SID altitude, so when alt sel with the altitude selector at 0 was pressed, plane went in alt locked mode.
Then now have a FMA saying HDG and alt locked with the altitude selector set at the SID. So you won't have any alt warning and altitude amber ...
Ofc, the FD was showing a horizontal bat at zero pithc in the ground and not +8 degree with GA mode, thet could have spotted it on the taxi checklist and they could have spotted it on the line up check list (check list ask to call FMA mode), was no alt sel arm white at all so it could have been spotted ... then when passing acceleration altitude, they could have seen the FD showing a deep descent and could have spot it there ... We end up about brain is good to see what is used to see and disregard what doesn't fit in his idea of reality.
How you explain the Emirates 777 with 3 crew trying to do a go around with idle ? They were used to have go around power set by autothrottle ... Expect in that case autothrottle was off due to the plane touching rwy...
Or how explain the airbus A320 in "mont Saint Odile" in France, instead of FPA 3degree they selected VS 3000ft/MN, they then we're focused of why the plane was speeding up ? I do remenrem one of the crew convincing himself saying, oh we have little bit of tail wing and plane really light today .... Brain see what he want to see ...
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I agree, mind can play tricks and if I remember correctly, Flybe use crosshair FD, while we use chevron type. I never liked the crosshair type, I think it can disappear from your perception too easily. Don't mean to start an AUDI VS BMW or PC VS MAC debate here, just my personal opinion
"Mildly" Eccentric Stardriver
Martin and Flocks. I guess your bias depends on what you have the most experience of. 95% of my FD time is on crosshairs, and I never really liked chevrons. I guess someone with the opposite experience would say the opposite.
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A few separate points:
1. The question is still open: on the avionics in question, can you have active guidance modes with the FD hidden from view? Because my mind boggles at trying to imagine anyone - at any point along the automation dependency spectrum - merrily flying along in an initial climb with a visible FD commanding a pitch into the ground, and then engaging the AP in this state.
2. Prior to engaging the AP, if they were climbing with a visible FD pointing at the ground, I can easily imagine this (unfortunately). One of the aspects of the automation dependent culture is a taboo against not having the FD up, even if it's 100% inappropriate. I remember a sim session where we did a PRM breakout, and in the 90 degree turn away from the airport, (I was PF) I was turning against the FD, which was still commanding a turn back onto the localizer; and the PM was talking on the radio so I couldn't ask him to set it to heading and set the bug. So the FD at that point was counterproductive (i.e., worse than useless) so I reached up and turned it off to avoid the distraction. I got scolded for doing this. Yes, in the instructor's absurd conception, it was better in the interim to have it up and pointing the wrong way than to turn it off. "All available resources," right? (Imagine explaining this scenario to the inventor of the FD.) So if this crew had gotten flogged in the past by instructors in a culture like this, I can certainly see how if they bungled the settings before takeoff, they would have felt more comfortable having a wrong-pointing FD than not having one.
3. Once they engaged the AP and were in (ahem) "plummet" mode, I wonder if they spent those 15 seconds distracted away from noticing the plummet, or were in the often-fatal "what's it doing now" conversation.
1. The question is still open: on the avionics in question, can you have active guidance modes with the FD hidden from view? Because my mind boggles at trying to imagine anyone - at any point along the automation dependency spectrum - merrily flying along in an initial climb with a visible FD commanding a pitch into the ground, and then engaging the AP in this state.
2. Prior to engaging the AP, if they were climbing with a visible FD pointing at the ground, I can easily imagine this (unfortunately). One of the aspects of the automation dependent culture is a taboo against not having the FD up, even if it's 100% inappropriate. I remember a sim session where we did a PRM breakout, and in the 90 degree turn away from the airport, (I was PF) I was turning against the FD, which was still commanding a turn back onto the localizer; and the PM was talking on the radio so I couldn't ask him to set it to heading and set the bug. So the FD at that point was counterproductive (i.e., worse than useless) so I reached up and turned it off to avoid the distraction. I got scolded for doing this. Yes, in the instructor's absurd conception, it was better in the interim to have it up and pointing the wrong way than to turn it off. "All available resources," right? (Imagine explaining this scenario to the inventor of the FD.) So if this crew had gotten flogged in the past by instructors in a culture like this, I can certainly see how if they bungled the settings before takeoff, they would have felt more comfortable having a wrong-pointing FD than not having one.
3. Once they engaged the AP and were in (ahem) "plummet" mode, I wonder if they spent those 15 seconds distracted away from noticing the plummet, or were in the often-fatal "what's it doing now" conversation.
Last edited by Vessbot; 11th Nov 2018 at 05:39.
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Interesting incident.
Experienced crew on board, certainly the Captain, so I think its a bit quick to assume automation dependency.
If you consider no FMA annunciations, no GA, no ALT etc and just look at where the FD is?
Are the pink bars/mustache pointing to the sky?
No....
If its not pointing to the sky, its not correctly set. STOP and correct it.
Isn’t it the case however that when ‘we’ are feeling rushed, that is exactly the time to slow down, you know there will be errors, let us create the time we need to catch and fix them. Unfamiliar airport, tired from these preceding duties I would not be adding distractions with single engine taxi or other frivolous distractions.
TEM.
My biggest concern is that it took 15 seconds or so to notice the aircraft was not doing as it should be. Where was the scan, what were they doing? The PF’s eyes should be focused on the flight path and nothing else. PM should be backing him up, checklists can come later, much later.
Experienced crew on board, certainly the Captain, so I think its a bit quick to assume automation dependency.
If you consider no FMA annunciations, no GA, no ALT etc and just look at where the FD is?
Are the pink bars/mustache pointing to the sky?
No....
If its not pointing to the sky, its not correctly set. STOP and correct it.
Isn’t it the case however that when ‘we’ are feeling rushed, that is exactly the time to slow down, you know there will be errors, let us create the time we need to catch and fix them. Unfamiliar airport, tired from these preceding duties I would not be adding distractions with single engine taxi or other frivolous distractions.
TEM.
My biggest concern is that it took 15 seconds or so to notice the aircraft was not doing as it should be. Where was the scan, what were they doing? The PF’s eyes should be focused on the flight path and nothing else. PM should be backing him up, checklists can come later, much later.