The Atlantic Glider revisited - official report released (Merged)
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Here are plots from the official Incident report
Glide data from the moment the plane became a glider until "landing"
Distance and Speed vs Time
Speed, Glide Ratio (10x), and Vertical Rate (fpm)
I'm surprised they were able to get an initial glide ratio of 24 which is very high !! I was expecting 17 or less.
Note: The distance and speed is obtained from radar data; in other words it's the radial distance to the radar.
Glide data from the moment the plane became a glider until "landing"
Distance and Speed vs Time
Speed, Glide Ratio (10x), and Vertical Rate (fpm)
I'm surprised they were able to get an initial glide ratio of 24 which is very high !! I was expecting 17 or less.
Note: The distance and speed is obtained from radar data; in other words it's the radial distance to the radar.
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I've just seen a program on TV about this with the normal media 'hero worship'.
Journo's love a good story, facts are sometimes inconveniences that have to be ignored. Heroes sell papers etc
You WANT heroes - then look to Sioux City, those guys were heroic.
Hero is a most over-used term these days.
Fact: the crew were dealt a really nasty incident.
Conjecture: You could argue that this fell outside the checklist.
BUT am I wrong in thinking that blind, slavish acceptance of checklist is WRONG?
If it isn't then you've made the case for the trained monkey instead of individuals who do LOFTs, CRM, Tech Refreshers, Line Checks etc etc.
It became obvious early doors that the drill wasn't making the situation better. Surely any thinking person can differentiate between a fuel imbalance and a leak. Fuel imbalance IMPROVES when you take action, Fuel LEAK doesn't.
My old time military checklists used to add a phrase along the lines of:
This checklist constitutes the best advice currently available but may have to be modified and is no substitute for sound judgement and good airmanship (can't remember the exact phrase).
When do you STOP feeding a fuel leak?
It's NOT brain surgery. You're in the middle of the pond and your crossfeed is open and downstream fuel is disappearing too damn quick.
So, lets just keep going until it's empty?
Sound judgement and good airmanship? I don't think so.
Given they were IN the position, they did well to get to land.
Wouldn't any of you made the same decision given the lack of noise?
This to me, smacks of slavish following of checklist without any thought of 'what are the implications of what I'm doing?'. Poor CRM and poor judgement. Smacks of some more heroes - Kegworth.
Personally, my view is that had the questions been asked, and the gauges been viewed and interpreted, they could have landed at Santa Maria with an engine running.
OK, I'm now ducking to avoid incoming.
It's incidents like this of 'heroes' that remind me of the Viscount that ran out of noise just short of Bournemouth a few years back.
Due to fuel gauge problems and a failure to reconcile fuel uplift, this crew ran out of fuel short of their DESTINATION let alone their ALTERNATE. They flopped into a field and everybody got out.
The passengers clapped as the pilots came out of the cabin, the press hailed them as 'HEROES'.
I rest my case.
The Edit: Marks have been deducted for spelling and grammar- apologies for the stuff I've missed.
Journo's love a good story, facts are sometimes inconveniences that have to be ignored. Heroes sell papers etc
You WANT heroes - then look to Sioux City, those guys were heroic.
Hero is a most over-used term these days.
Fact: the crew were dealt a really nasty incident.
Conjecture: You could argue that this fell outside the checklist.
BUT am I wrong in thinking that blind, slavish acceptance of checklist is WRONG?
If it isn't then you've made the case for the trained monkey instead of individuals who do LOFTs, CRM, Tech Refreshers, Line Checks etc etc.
It became obvious early doors that the drill wasn't making the situation better. Surely any thinking person can differentiate between a fuel imbalance and a leak. Fuel imbalance IMPROVES when you take action, Fuel LEAK doesn't.
My old time military checklists used to add a phrase along the lines of:
This checklist constitutes the best advice currently available but may have to be modified and is no substitute for sound judgement and good airmanship (can't remember the exact phrase).
When do you STOP feeding a fuel leak?
It's NOT brain surgery. You're in the middle of the pond and your crossfeed is open and downstream fuel is disappearing too damn quick.
So, lets just keep going until it's empty?
Sound judgement and good airmanship? I don't think so.
Given they were IN the position, they did well to get to land.
Wouldn't any of you made the same decision given the lack of noise?
This to me, smacks of slavish following of checklist without any thought of 'what are the implications of what I'm doing?'. Poor CRM and poor judgement. Smacks of some more heroes - Kegworth.
Personally, my view is that had the questions been asked, and the gauges been viewed and interpreted, they could have landed at Santa Maria with an engine running.
OK, I'm now ducking to avoid incoming.
It's incidents like this of 'heroes' that remind me of the Viscount that ran out of noise just short of Bournemouth a few years back.
Due to fuel gauge problems and a failure to reconcile fuel uplift, this crew ran out of fuel short of their DESTINATION let alone their ALTERNATE. They flopped into a field and everybody got out.
The passengers clapped as the pilots came out of the cabin, the press hailed them as 'HEROES'.
I rest my case.
The Edit: Marks have been deducted for spelling and grammar- apologies for the stuff I've missed.
Last edited by Dengue_Dude; 28th Oct 2004 at 11:12.
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LZ
I don't think anybody has said that anything was installed backwards. If your post was making this assumption, than a very elequant post it is, but nothing to do with this incident.
The problem was a properly documented RR mod package, which was only half incorporated (some pre-Mod bits and some post-Mod).
The problem was not really RR's. It was with the procedures (or lack of) when the engine change occurred. It was not helped by some of the contractual arrangements and expectations in the "pool" engine arrangments, and who was responsible for incorporating mods etc.
NoD
One aspect of this checklist would be directed at parts or assemblies that could be installed backwards. In the case of the Air Transat engine this would include the fuel line and the hydraulic line both of which could be installed backwards
The problem was a properly documented RR mod package, which was only half incorporated (some pre-Mod bits and some post-Mod).
The problem was not really RR's. It was with the procedures (or lack of) when the engine change occurred. It was not helped by some of the contractual arrangements and expectations in the "pool" engine arrangments, and who was responsible for incorporating mods etc.
NoD
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4 u space-cadettes out there, one more figure, for the gipper ...
Air Transat 236's last 31 minutes just as the 2 engines were starving for fuel.
He did very good stable gliding at the beginning and on final to the runway !!
What I was mainly interested in was the Glide Ratio which is rarely ever mentioned. In this case it was 24 which is very good/high (but i was expecting 17). A well designed glider-plane will do 40 - 50 (or 40 miles distance whilst losing only 1 mile in altitude). From 10000ft you could glide 100 miles without any power on these professional gliders. For a Boeing or Airbus it could glide 100 miles from an altitude of 20000 feet without power !!
He seemed to have glided at approx 250 knots ground speed (nautical miles per hour) (or 200 knots indicated airspeed). So next time you have to glide-in your Boeing or Airbus make sure you keep that airspeed of 200 knots on the instrument !!! Too fast or too slow and you lose more altitude !!!!!
Glossary:
min: minutes
nm: nautical miles
FL: Flight Level (almost exactly same as altitude)
Speed: speed towards radar on island
Descent: vertical speed in feet per minute
Glide Ratio: Forward speed divided by downward speed
Air Transat 236's last 31 minutes just as the 2 engines were starving for fuel.
He did very good stable gliding at the beginning and on final to the runway !!
What I was mainly interested in was the Glide Ratio which is rarely ever mentioned. In this case it was 24 which is very good/high (but i was expecting 17). A well designed glider-plane will do 40 - 50 (or 40 miles distance whilst losing only 1 mile in altitude). From 10000ft you could glide 100 miles without any power on these professional gliders. For a Boeing or Airbus it could glide 100 miles from an altitude of 20000 feet without power !!
He seemed to have glided at approx 250 knots ground speed (nautical miles per hour) (or 200 knots indicated airspeed). So next time you have to glide-in your Boeing or Airbus make sure you keep that airspeed of 200 knots on the instrument !!! Too fast or too slow and you lose more altitude !!!!!
Glossary:
min: minutes
nm: nautical miles
FL: Flight Level (almost exactly same as altitude)
Speed: speed towards radar on island
Descent: vertical speed in feet per minute
Glide Ratio: Forward speed divided by downward speed
Iconoclast
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Now let me see, which way do these parts go?
To: NigelOnDraft
The cannibalized parts (tubes) that were taken from the RB-211 engine were installed backwards. These parts were interchangeable with the tubes that should have been delivered with the engine (but they were not). Both tubes had identical "B" nuts at each end of the respective tubes. Good design would have dictated different types/sizes of "B" nuts or at the very least specific instructions as to how the tubes should be installed including the establishment of clearance between the two tubes.
That’s the story I got from my sources and I’m sticking with it.
I don't think anybody has said that anything was installed backwards. If your post was making this assumption, than a very elequant post it is, but nothing to do with this incident.
That’s the story I got from my sources and I’m sticking with it.
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Just the facts, Lu
Mr Z, you seem very insistent on blaming the engines...a previous bad experience ?
Rereading the official report, page 16 :
In fact, it’s a requirement for the airline who installs the core engine to check its configuration and receipt and ensure that it complies with the manufacturers specifications.
and on page 18 :
the scratches and scores were directionally aligned and that they could have been caused from repeated contact from a blunt instrument, such as a screwdriver being inserted be-tween the tubes in order to force a clearance between them. There were no cracks initiated from the score or scratch marks
So, it appears to me that someone inspected the (incorrect) arrangement of tubes etc, and attempted to force them into a suitable clearance.
On page 17 :
It was evident that the interference and chafing occurred due to the mismatched installation of the post-mod fuel tube (P/N: FK30383) and pre-mod hydraulic tube (P/N: LJ51006).
The Mod in question, SB72-C625 says (on page 7 of the SB) :
Interchangeability of Parts : (1) It is essential that the parts are fitted as a set.
So. What are the facts about this "backward pipe fitting" story?
Rereading the official report, page 16 :
In fact, it’s a requirement for the airline who installs the core engine to check its configuration and receipt and ensure that it complies with the manufacturers specifications.
and on page 18 :
the scratches and scores were directionally aligned and that they could have been caused from repeated contact from a blunt instrument, such as a screwdriver being inserted be-tween the tubes in order to force a clearance between them. There were no cracks initiated from the score or scratch marks
So, it appears to me that someone inspected the (incorrect) arrangement of tubes etc, and attempted to force them into a suitable clearance.
On page 17 :
It was evident that the interference and chafing occurred due to the mismatched installation of the post-mod fuel tube (P/N: FK30383) and pre-mod hydraulic tube (P/N: LJ51006).
The Mod in question, SB72-C625 says (on page 7 of the SB) :
Interchangeability of Parts : (1) It is essential that the parts are fitted as a set.
So. What are the facts about this "backward pipe fitting" story?
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Don't we live in a BLAME culture?
The crew had ONE failure - be completely clear about it. ONE failure should not cause the potential loss of the aircraft.
Let's substitute the word RESPONSIBILITY for the word 'blame'.
Given the HANDLING of their one failure, once it had resulted in the double hush - they then did quite well.
When they shave in the morning they are looking at the people responsible for getting into the more serious situation in the first place.
Computer fault, engine component failures, Murphy's etc aside - they were NOT the reason for a double flameout.
The crew WERE.
Remember a SINGLE component failure - isn't ETOPS based upon that? But, competently handled, it is SAFE.
They are paid as professionals, trained as professionals, trusted by the pax as professionals and sadly didn't act like professionals UNTIL they ended up with no engines - then in many respects they redeemed themselves (out of sheer desperation probably, nevertheless everybody got out and I suppose that's the result that sticks in the travelling public's mind).
It's really that simple. All the rest is moving air around at 37 degrees C.
edited for grammar this time DD
The crew had ONE failure - be completely clear about it. ONE failure should not cause the potential loss of the aircraft.
Let's substitute the word RESPONSIBILITY for the word 'blame'.
Given the HANDLING of their one failure, once it had resulted in the double hush - they then did quite well.
When they shave in the morning they are looking at the people responsible for getting into the more serious situation in the first place.
Computer fault, engine component failures, Murphy's etc aside - they were NOT the reason for a double flameout.
The crew WERE.
Remember a SINGLE component failure - isn't ETOPS based upon that? But, competently handled, it is SAFE.
They are paid as professionals, trained as professionals, trusted by the pax as professionals and sadly didn't act like professionals UNTIL they ended up with no engines - then in many respects they redeemed themselves (out of sheer desperation probably, nevertheless everybody got out and I suppose that's the result that sticks in the travelling public's mind).
It's really that simple. All the rest is moving air around at 37 degrees C.
edited for grammar this time DD
