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EK 231 20 December DXB IAD near crash?

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EK 231 20 December DXB IAD near crash?

Old 23rd Feb 2022, 12:28
  #321 (permalink)  
 
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I think someone pointed out earlier that this is what you get when the Children of the Magenta Line meet the Climate of Fear: Itís better to have an accident following rules, even if they are no longer sensible in the situation, than to save the day by thinking outside the box (or using common sense, as above).

It comes down in the end as to why we (pilots) are there in the first place? Is it to make sure we follow regulations and best practice as much as possible? Yes, thatís part of it, but the *real* reason we sit at the front is for the time when the rules donít apply, or would make the situation worse. Not that long ago I attended a live training presentation on deliberate rule-breaking and how it was an essential part of safety culture; the message had obviously made it to the top that mental flexibility was paramount when dealing with situations outside the scope of normal operations.
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Old 23rd Feb 2022, 13:15
  #322 (permalink)  
 
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Originally Posted by FullWings
I think someone pointed out earlier that this is what you get when the Children of the Magenta Line meet the Climate of Fear: Itís better to have an accident following rules, even if they are no longer sensible in the situation, than to save the day by thinking outside the box (or using common sense, as above).

It comes down in the end as to why we (pilots) are there in the first place? Is it to make sure we follow regulations and best practice as much as possible? Yes, thatís part of it, but the *real* reason we sit at the front is for the time when the rules donít apply, or would make the situation worse. Not that long ago I attended a live training presentation on deliberate rule-breaking and how it was an essential part of safety culture; the message had obviously made it to the top that mental flexibility was paramount when dealing with situations outside the scope of normal operations.
Interestingly my airline has started in the last years to have a training day with various stretch scenarios. These are non graded and allow us to deviate from SOP etc as needed and as allowed in emergency situations. Itís been a fantastic breath of fresh air to not have to worry about what the trainer thinks but rather just focus on getting a safe outcome from the unusual scenario presented to us.


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Old 12th Apr 2022, 21:52
  #323 (permalink)  
 
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FAA has issued SAIB AIR 22-09
SUBJ: AUTOPILOT FLIGHT DIRECTOR SYSTEM:
ALT HOLD Engaged on Takeoff on Boeing Model 777/787 common fleets.


https://rgl.faa.gov/Regulatory_and_G.../AIR-22-09.pdf

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Old 12th Apr 2022, 23:52
  #324 (permalink)  
 
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A bulletin. Good.

Now how do we weed out the pilots who will take 350 passengers, roll them off the end of the runway and then fly blissfully towards an apartment building without it occurring to them that the situation is somewhat undesirable?
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Old 13th Apr 2022, 00:11
  #325 (permalink)  
 
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And no where in the bulletin does it "recommend" simply flying the A/C. Surely they cant assume that's a given?
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Old 13th Apr 2022, 15:56
  #326 (permalink)  
 
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This issue should have been identified during design, (system specification and vendor build) and/or manufacturer checking and testing.
Perhaps Boeing did not know of this, neither the FAA - deficient process

Alternatively, the issue was identified, but accepted as a crew management task dependant on system description and procedures, although none have been identified “… this specific scenario is not explicitly described …” (FAA SAIB)

Reliance on crew knowledge and procedure is difficult to judge, perhaps biased by the Boeing philosophy defaulting to crew choice, always in the loop, desription, procedure, vice system inhibits; recent 737 history identified flawed thinking.
Also the FAA, with knowledge, could have judged the issue as not meeting the requirements, but similarly with recent history, judgement can be bypassed by self certification or poor system knowledge by those responsible for oversight.

25.1302 assumes operation by a trained crew, but if the system description is poor or non existent, then the requirement is not met: … does the simulator behave in the same way as the aircraft ?
Similar issues with the 777 AT going to ‘sleep’; modifications followed ?
This issue warrants modification, but when, by whom ?
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Old 16th May 2022, 13:48
  #327 (permalink)  
 
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This issue should have been identified during design, (system specification and vendor build) and/or manufacturer checking and testing.
Perhaps Boeing did not know of this, neither the FAA - deficient process
On principle you are correct - yet it took about 25+ years for anyone to notice (maybe some other operator did encounter this but their pilot actualy had the amazing proficiency to actualy rotate the plane at takeoff...)
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Old 16th May 2022, 22:39
  #328 (permalink)  
 
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Originally Posted by Wizofoz
And EK reaps what it sows, and learns nothing.

The Joberg over-run years ago? Bad training and over relience on generated, rather than raw information.

The 777 hull loss, including a fatality? bad training and fear culture coupled with too much relience on automation.

This one? Ddidn't rotate because the FD didn't say to? Really???

Not long before leaving I had a (non) incident,complete with frog-march to the office, becaue I disconnected the AP to correct a rapidly decreasing airspeed due to windshear and the 777s habit of going into ALT CAP early.

The verdict? You should have let the automation deal with it until stck shaker.

Thise who do not learn from the past are apt to repeat it....
With such a company culture, how is it possible that they still did not crash an airplane ?
They had one hull loss but no complete crash.
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Old 17th May 2022, 09:58
  #329 (permalink)  
 
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Originally Posted by CVividasku
With such a company culture, how is it possible that they still did not crash an airplane ?
They had one hull loss but no complete crash.
itís called luck. Airlines have been using it as their primary safety program for years
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Old 18th May 2022, 05:00
  #330 (permalink)  
 
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Good example of 'Boeingspeak" - it's not our fault!



"While altitude hold latching and TO/GA behaviors are described in the Boeing Flight Crew Operations Manual (FCOM), this specific scenario is not explicitly described. It is apparent that this specific system behavior may not be known to all pilots of these aircraft."
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Old 18th May 2022, 22:33
  #331 (permalink)  
 
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Thereís some of a point there, but it really comes under the umbrella of mode awareness? There are 6 autothrottle modes, 10 roll and 11 pitch ones, which is 660 combinations. OK, not all of those are likely or even possible, but there are still a significant number. Rather than trying to learn a fixed response to every possibility, it might be better to recognise that not all is well in FMA land and to correct the flightpath, either through appropriate use of automation or manual intervention...?
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Old 19th May 2022, 06:55
  #332 (permalink)  
 
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Exactly. This auto-thrust 'hold' mode where it goes to sleep and ignores decaying IAS, seems absolutely bonkers to me, BUT pilots should always monitor their aircraft.

If the automatics are not doing what is required, the pilots need to step in and do something about it.

That is precisely why we have pilots - can you imagine the carnage if aircraft were autonomous
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Old 19th May 2022, 07:25
  #333 (permalink)  
 
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Uplinker, ďexactlyĒ Ö exactly.
ďIf the automatics are not doing what is required,Ē this requires a plan, the knowledge of what is required; and then an awareness that the current situation is not as required.

FullWings ďunder the umbrella of awarenessĒ.
Awareness is a combination of knowledge and interpretation, awareness is an attribute of human behaviour affected by many circumstantial factors, thus cannot be foreseen.

We should not judge awareness, knowledge or interpretation in isolation, but with a holistic view, try to understand all factors and points of view.
The industry needs to move on from yes - no, hard decisions, SOP culture, towards maybe - what if, skills of judgement to help manage (our) uncertainty.
Its easy for us to be certain after the fact, but remain uncertain if this view has safety value - what could we learn.
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Old 19th May 2022, 07:45
  #334 (permalink)  
 
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Some great points made above. Thinking back a whiles to my old airlines, we taught how and when to deviate from SOPs. Critical thinking and rule breaking were on the CRM syllabus along with managing an aircraft across cultures. Some airlines introduced checklists with steps, mid critical actions that said...." Fly the Aircraft ".... elec ##...off..reset....."Fly the Aircraft"....
Some a/c manufacturers go very quiet when something happens that they really don't like and then they take years to close off the issue.
A heavy Boeing with its (unheated) ....elevator covered in ice shaking the whole shooting match to blazes on the approach to London. No can't happen.... yes it did.... and there is the picture for Seattle. The heavy boeing with a batt bus failure that tripped off the whole AC elec system with terrible results. Can't happen say the manufacturer...probably Crew error. Not crew error, they saved the day with critical thinking.
Thank goodness for modern CRM training.
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Old 19th May 2022, 15:36
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That is precisely why we have pilots - can you imagine the carnage if aircraft were autonomous
Well for the better or worse this is where we are going, just as with cars. Probably still 30-50 years out but I'm pretty convinced this will be the norm eventually, and, most likely, we will be better off (although zero risk is obviously not possible).
In any case out of the scope of this specific discussion.


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Old 20th May 2022, 09:23
  #336 (permalink)  
 
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A human pilot, while able to make an errors of judgement, mis handle, make a slip, a lapse or a mistake can do something quite special that no automation or bot can do.

The human pilot can safely ecover a badly stricken aircraft using skills, experience and fine judgements that would not be available with automation or a bot. So many examples from military and airline history.
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Old 20th May 2022, 10:31
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zamboni, “… just as with cars”.
This is not necessarily the future of aviation.

Cars aim for the complete works - driverless; with hard lessons being learnt so far, accidents, fatalities. And whilst statistically safe, the performance does not match public expectation; latterly this is being alleviated by requiring a car-human combination. This too is flawed thinking, using a very poor human monitor, to monitor or take over from very complex technology.

Commercial aviation at least, appears to be starting with a man-machine combination, where the strengths and weakness of each are considered as a balanced whole (proposals for reduced crew operations).

Unfortunately this approach has yet to be introduced in system design and certification. Thus this incident represents various human weaknesses in the design and certification processes before the event, as much as the event itself; where deficiencies are currently only identified with hindsight.

A further issues if a human based safety management (design, certification, and incident investigation), with inherent human limitations (error), will be more unreliable than the operation itself. Safety management looks for error, it will find error; however who's error, safety management or operation.

“… the mind creates maps of reality in order to understand it, because the only way we can process the complexity of reality is through abstraction. … that we will frequently use an incorrect model simply because we feel any model is preferable to no model.”

“A model might show you some risks, but not the risks of using it.”
.

Last edited by alf5071h; 21st May 2022 at 08:45. Reason: ‘design, certification, and incident investigation’
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Old 20th May 2022, 12:38
  #338 (permalink)  
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Originally Posted by Right20deg
A human pilot, while able to make an errors of judgement, mis handle, make a slip, a lapse or a mistake can do something quite special that no automation or bot can do.

The human pilot can safely ecover a badly stricken aircraft using skills, experience and fine judgements that would not be available with automation or a bot. So many examples from military and airline history.
Your observation is quite valid. The reliance on automation moves the center of error usually from the pilot towards the system architecture and embedded logic, which is great when it works, and not so great when it doesn't. You don't need Kev Sullivan's cosmic radiation bit flip to mess you up, something as simple as AA 965 disclosed the hidden issue with ARINC standards. Sure, a crew should have picked up the problem, that is what we train to do and try to do, but on one dark night, the operational change resulted in reduced cognitive capacity just as the time available to avoid a disaster went to zero. Both automation and crew processes fell over in that case, but only one had any chance of being able to catch the problem but ran out of time.

Running off the end of the runway as the FD bar is zero attitudes is still incomprehensible as an SA state for any pilot that went solo in a bug smasher, or could drive a car, or ride a bike. The airline concerned needs to go and do a collective belly button contemplation as to how they ended up with that being a solution selected by a trained pilot, as it suggests a gross failure of the total system, not just the pilot, unless, the pilot happened to have a brain tumor or other cognitive impairment. Now, the B777 did have a miserable day many years ago with a high-speed RTO in Nigeria, where the AP had accidentally been engaged, and the driver felt severe restriction when pulling back on the controls. That was an ugly day out and set the manufacturer to print an AOM on the matter, but... golly, following a FD on the ground, is a weird state of affairs, and more bizarre when the guidance is illogical. What has our industry become?
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Old 20th May 2022, 14:08
  #339 (permalink)  
 
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Originally Posted by EcamSurprise
Interestingly my airline has started in the last years to have a training day with various stretch scenarios. These are non graded and allow us to deviate from SOP etc as needed and as allowed in emergency situations. It’s been a fantastic breath of fresh air to not have to worry about what the trainer thinks but rather just focus on getting a safe outcome from the unusual scenario presented to us.
ECAMSurprise,
When I flew C-17’s in the AF, we would get a sim session where they simulated a missile strike. Obviously this caused multiple simultaneous systems damage beyond your standard scenarios. As you stated, it was extremely valuable training, as there were no checklists to refer to in some of these situations. The goal was to use systems knowledge, experience, and Airmanship to get the aircraft on the ground safely. A great example of this was a scenario where a missile struck an engine and destroyed it, also causing a large fuel leak in an adjacent fuel tank feeding a good engine. Instead of trying to analyse the fuel/engine issues, we learned to open all fuel crossfeeds, thereby ensuring all remaining engines would be supplied with fuel, while we tried to land, exceptional training.
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Old 21st May 2022, 07:43
  #340 (permalink)  
 
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Originally Posted by fdr
Your observation is quite valid. The reliance on automation moves the center of error usually from the pilot towards the system architecture and embedded logic, which is great when it works, and not so great when it doesn't. You don't need Kev Sullivan's cosmic radiation bit flip to mess you up, something as simple as AA 965 disclosed the hidden issue with ARINC standards. Sure, a crew should have picked up the problem
Running off the end of the runway as the FD bar is zero attitudes is still incomprehensible as an SA state for any pilot that went solo in a bug smasher, or could drive a car, or ride a bike. The airline concerned needs to go and do a collective belly button contemplation as to how they ended up with that being a solution selected by a trained pilot, as it suggests a gross failure of the total system, not just the pilot, unless, the pilot happened to have a brain tumor or other cognitive impairment. Now, the B777 did have a miserable day many years ago with a high-speed RTO in Nigeria, where the AP had accidentally been engaged, and the driver felt severe restriction when pulling back on the controls. That was an ugly day out and set the manufacturer to print an AOM on the matter, but... golly, following a FD on the ground, is a weird state of affairs, and more bizarre when the guidance is illogical. What has our industry become?
______________________________________________
You make important points. The airline responsible has a 'big issue' with training and culture, all held together with fear. The CRM and safety industry in the west has been aware of this for some time. This airline spends many days a year studying crew resource management.
The cabin crew are controlled in the severest of fashion.
To be candid...." all the gear but no idea" . Such a shame that this is the case.
Rgds R20deg
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