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B-737 Cargo Plane down in Hawaii

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B-737 Cargo Plane down in Hawaii

Old 18th Jun 2023, 13:09
  #321 (permalink)  
 
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As an SLF, it certainly seems illogical to conclude you have two malfunctioning engines and try to continue flying with only one of them.
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Old 18th Jun 2023, 14:08
  #322 (permalink)  
 
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Originally Posted by Chu Chu
As an SLF, it certainly seems illogical to conclude you have two malfunctioning engines and try to continue flying with only one of them.
An insightful and thought-provoking comment.
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Old 18th Jun 2023, 17:02
  #323 (permalink)  
 
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My first listen to the audio recording of the incident.

I didnt know wether to laugh or cry at the R/T back and forth.

I suspect the amount of time spent (mis)communicating on the radio was at the very least a contributing factor to what would have become a single pilot operation.

But at least the "trucks rolled"!!!
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Old 18th Jun 2023, 22:55
  #324 (permalink)  

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If rigid adherece to a NNC (pleonasm, BTW, not-non-adherence?) is what prevents the crew from rushing themselves 6 feet under, then let the flogging begin preemptively I say.

A NNC shall be performed from the beginning, until the end, in the listed sequence, without skipping any items.

Shouldn't be that hard BIG-BUT-HERE: each of us needs a role model to show him how to walk the walk and work the work all the way to the full mile. It still takes a pro to mentor a good pilot out of a talented licence holder.



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Old 19th Jun 2023, 07:27
  #325 (permalink)  
 
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Should be an important task for the FAA to figure out, why the two in row 0 never tried to open the throttle of the other idling engine, when the in their mind "good one" could not keep altitude.
Compared to swim they cold hardly loose. So why both where so task saturated that the simple solution never occurred to them.
They did the first right thing and did not shut the engine down, as other did before and tried to relight it in vain. They where so close in saving the night.
Easy to say from the arm chair, but there is something to learn here.
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Old 19th Jun 2023, 10:58
  #326 (permalink)  
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Originally Posted by EDLB
Should be an important task for the FAA to figure out, why the two in row 0 never tried to open the throttle of the other idling engine, when the in their mind "good one" could not keep altitude.
Compared to swim they cold hardly loose. So why both where so task saturated that the simple solution never occurred to them.
They did the first right thing and did not shut the engine down, as other did before and tried to relight it in vain. They where so close in saving the night.
Easy to say from the arm chair, but there is something to learn here.
The point that the cognitive error occurred is identifiable in the CVR, the PIC verbalises the failed engine as #1 whereas the FO had previously determined #2 to have failed. The PIC had assumed PF just before this, and it appears he had made a thrust reduction, and had brought #1 back around this time, and had a cognitive slip. The point of opening up any thrust lever would have saved the flight is valid, the problem is the crew are fighting a confusing SA condition which adds stress to their processes, and that reduces the bandwidth either pilot had to do a simple reasonableness assessment. It is possible to lose two engines, it is not likely, and it is far more likely for a crew to select the wrong engine as the cause of their problems. If the energy state is decaying, adding any lever tooth mix of more noise can only be beneficial.

The CVR is not pretty, the NTSB is making a fashion statement with leaving the complete conversation in the transcript, it should be a learning point on the concept of policy, practices and specifically reduction of extraneous activity in critical phases of flight. While it reads polly, it is closer to what is observed in many operations when undertaking IOSA audits. Humans act as humans do.

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Old 19th Jun 2023, 12:09
  #327 (permalink)  
 
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I agree that by publishing the full CVR they are saying something. Why they canít state that the crew were lacking any sort of discipline I donít know.

They were talking about anything but the operation the entire time and the interaction between the two pilots and ATC was crammed with extraneous verbal diarrhoea which only added to workload/stress leaving no cognitive capacity to deal with the ONLY thing that mattered.

Like I said; itís cringe worthy stuff and coming from the US is just embarrassing.
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Old 19th Jun 2023, 14:24
  #328 (permalink)  
 
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Sounds pretty standard for US ATC RT.
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Old 19th Jun 2023, 18:02
  #329 (permalink)  
 
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If you read the CVR transcript, https://data.ntsb.gov/Docket/Documen...elease-Rel.pdf
the most important item, validation the faulty engine, gets the least amount of attention. They spent 4 minutes on RT after identifying the true defective engine and after the RT they stick to the wrong one.
On a jet you don't face much of drag problem of a faulty engine, so no need to shut down anything quick unless on fire. That part they did right. And before ditching try anything which can increase the noise level.
Simple with 20-20 hindsight from the armchair. The question remains, why did they not go back into problem identifying when the assumed good engine could not keep altitude?
They had 4 minutes from realizing that to ditching. 141.10 to 145.17
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Old 20th Jun 2023, 01:13
  #330 (permalink)  
 
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Originally Posted by EDLB
If you read the CVR transcript, https://data.ntsb.gov/Docket/Documen...elease-Rel.pdf
the most important item, validation the faulty engine, gets the least amount of attention. They spent 4 minutes on RT after identifying the true defective engine and after the RT they stick to the wrong one.
On a jet you don't face much of drag problem of a faulty engine, so no need to shut down anything quick unless on fire. That part they did right. And before ditching try anything which can increase the noise level.
Simple with 20-20 hindsight from the armchair. The question remains, why did they not go back into problem identifying when the assumed good engine could not keep altitude?
They had 4 minutes from realizing that to ditching. 141.10 to 145.17
If they had focused on engines as much as they did on female pilots they would have easily identified where they went wrong.
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Old 20th Jun 2023, 02:28
  #331 (permalink)  
 
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Am I the only one who is wondering about the Captain's experience with engine failures? From the report:
Originally Posted by The NTSB
The captain reported that he had experienced about five engine failures while working at Rhoades Aviation. One such failure occurred about 3 to 4 months before the accident
WTF are they doing there such that the Skipper has a half-dozen actual failures under his belt before he went for a swim? Most crew will go their entire career without having a genuine engine failure outside the box. Precautionary shutdowns, certainly, but genuine hard failures? And this bloke has had 5 before this one - and that's with one company?!? Granted he's got a swag of hours, and I cant see from the report how long he's been employed by Rhoades, but still.....

Last edited by KRviator; 20th Jun 2023 at 02:29. Reason: Typo
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Old 20th Jun 2023, 07:02
  #332 (permalink)  
 
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About 5, in other words he’d lost count.
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Old 20th Jun 2023, 16:33
  #333 (permalink)  
 
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Orrrrrrr…. Bear with me…… he was unaware of what a failed engine looked liked?

Couldn’t possibly be true…
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Old 8th Jul 2023, 23:44
  #334 (permalink)  
 
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From the NTSB report:

"The NTSB considered whether fatigue played a role in the captainís errors, but the evidence was inconclusive." and "The NTSB also considered whether the first officerís errors were due to fatigue. Even though the errors that the first officer made were consistent with the effects of fatigue, the evidence supporting fatigue was inconclusive"

The Captain had worked 20 back side of the clock legs in the previous 3 nights, But the NTSB couldn't determine if fatigue was a factor? WTF? Of course it was a factor. Fatigue is the number one killer of crews and pax, especially for back side of the clock flying Freight Dogs.

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Old 8th Jul 2023, 23:50
  #335 (permalink)  
 
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It's probably fair to guess that both crew members were fatigued, the statement suggests that the investigators could not confidently state that it affected the crew actions and outcome of the flight. Would the crew have behaved in the same way if they were positively well-rested and at the top of their game (from the perspective of cognitive capabilities)?
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Old 9th Jul 2023, 00:08
  #336 (permalink)  
 
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Having done way too much of this type of flying hauling both pax and freight, i know that if I had flown the schedule that they (especially the captain) had flown, that my cognitive capabilities would be significatly impaired compared to my well rested sefl.

Here is what the FAA said about it, in FAA Circular 117-3, which "was developed to demonstrate acceptable methods of compliance with Title 14 Code of Federal Regulations (14 CFR) part 117, ß 117.5, Fitness for Duty".

"Fatigue is characterized by a general lack of alertness and degradation in mental and physical performance. Fatigue manifests in the aviation context not only when pilots fall asleep in the cockpit during flight, but perhaps more importantly, during the task-critical takeoff and landing phases of flight. Reported fatigue-related events have included procedural errors, unstable approaches, lining up with the wrong runway, landing without clearances, and poor decisionmaking."

Stress has the same affect, but adding fatigue to the equation will magnify any stress related congnitive impaiment. I can only speak for myself, but I know that I am much more at the "top of my game" if I am well rested.
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Old 31st Aug 2023, 02:31
  #337 (permalink)  
 
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Originally Posted by Boeingdriver999
I agree that by publishing the full CVR they are saying something. Why they canít state that the crew were lacking any sort of discipline I donít know.
Of course, during taxi conversations are supposed to be limited to topics required for the safe operation of the flight, which the NTSB have chosen to ignore here. The captain certainly seemed emotional, and neither of them were probably in the best mental state to handle an engine failure, especially given the conversation they'd been having not two minutes before it occurred.

It is indeed interesting that the NTSB have chosen to sweep this under the carpet. I wonder if it would be different if they'd been discussing, say, soccer, rather than the captain's apparently rather extensive list of grievances with one of his co-workers.

As part of the Safety Boardís accident investigation process, the flight crew was
invited to review the CVR transcript and suggest corrections or additions. They
declined the invitation.
I wonder why
Attached Files
File Type: pdf
DCA21FA174_CVR_Release-Rel.pdf (1.25 MB, 111 views)
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Old 1st Sep 2023, 10:56
  #338 (permalink)  
 
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Originally Posted by Boeingdriver999
I agree that by publishing the full CVR they are saying something. Why they canít state that the crew were lacking any sort of discipline I donít know.

They were talking about anything but the operation the entire time and the interaction between the two pilots and ATC was crammed with extraneous verbal diarrhoea which only added to workload/stress leaving no cognitive capacity to deal with the ONLY thing that mattered.............
I have read most of the report and the CVR transcript, and I agree.

From the report, this Captain was clearly not suitable to be a Captain. Although he sort of generally did what was required, he obviously did not do everything, did not look at details, and his mind was not focussed on the flight. During cockpit prep, there was a very long diatribe from the Captain about another F/O and full and free control checks, which was not appropriate.

Then during the emergency, there seems to have been a complete lack of procedure. I don't know the B737- 200 SOPs or checklists, but surely there must be a section to correctly identify a failed engine - using all the indications and all the engine gauges - and apply max continuous thrust to the good engine? Or wasn't this a procedure in the - 200 days?

From the start of the CVR transcript, this Captain was not being methodical, and he was not focussing on the task at hand. All that stuff about another pilot was irrelevant and a distraction which would have been best left for the hotel or the transport after their duty had finished.

During the emergency, the Captain accepted the F/Os word about the failed engine, but then somehow managed to swap that over in his head to the other engine. Unfortunately, the F/O did not correct him on this - I cannot think why, unless he too was overwhelmed by the situation.

There seem to be similarities between this accident and the UK Kegworth accident - both misidentifying a failed engine in a B737 and crashing with their one good engine at idle. Perhaps Boeing urgently need to review their engine fail procedures and SOPs - especially in the B737 - Classic and the B737 - Prehistoric.

But how did this Captain pass his recurrent Sim checks with his general lack of procedure and lack of attention to detail ? He was once pulled up for not following checklists, but that seems to have been about it.

I have always had doubts about airlines checking their own pilots in the Sim. Once, as PM in the Sim; I personally witnessed a new manager to the company 'handle' an EFATO a bit like this - vague, loose and not following the SOPs etc., although he did keep control of the aircraft. I thought to myself, oh dear how embarrassing, there will be words and he will have to do that all again - (had I not followed the prescribed procedures, I would definitely have been torn off a strip) - but amazingly, the company TRE said to him Yes.......that's all fine !!

As well as most problems in a Sim being blamed on the F/Os, I have personally seen sub-optimum PIC performance being nodded through, especially when a manager is being assessed by a TRE who is junior to that manager, but also a senior pilot being assessed by a TRE technically junior to them.

In terms of CRM, I got the impression - from his very short replies - that this F/O was wishing that the Captain would shut up about the other F/O, and just had his head down trying to get on with the flight - but he did not know how to make the Captain shut up. Later in the flight, the F/O says fly the plane please, or pull up please. Please ?? No need for "please" in an emergency. That suggests to me that the F/O felt he could not control the Captain until it got to the point when the F/O became fearful of a bad outcome, but even then he could not bring himself to directly order the Captain.

In CRM, we are shown accidents and CRM failures, but in my experience, F/Os have never actually been taught how to 'control' a Captain. Some know already but others don't, and it is not easy to override a difficult Captain, or make them behave in a cockpit during a flight. I have had to do it twice, (and once in a restaurant), with stern words, and it was not easy.
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