IMO the best post so far on this example of a complete and utter failure of professional standards of airmanship......

I crashed landed is some trees yesterday and whilst I was driving to get a chain saw I discussed this incident with my very capable mate.
French Carrier pilot who banged out twice, flew off American carriers, won a top gun prize and flew and instructed on executive jets.

He said every pilot initially panics - I disagreed and cited a occasion when I made a mayday - but realised that he was right.

It's what you do after the bang or you realise that you might crash that is important....

Look at the BOAC 707 which crashed at LHR in the 60s where they decided to do an instant return and got the fire drill wrong.

The 777 splat at LHR where they carried out the after crash drill in the wrong sequence.fortunately there was no fire otherwise their mistake could have been disastrous.

AirFrance where the copilot was so scared he held on back stick pressure (allegedly).

In my old airline we had a captain lock himself into the loo when the destination closed in fog and there weren't a lot of alternate airfields.

Sadly none of us know what we will do when it hits the fan and most of us luckily will never have to face the mire.

What we can do is lots of professional training and that comes back down to money, professionalism and a realisation that we can all make mistakes......

Not forgetting aviation authorities doing a proper job and not looking after their mates...

I reckon there should be a SILENCE button that shuts down the squarking banshee, when required.

A recent failure of a PFM Box, saw 15 minutes or so of constant squarking from Mrs Douglas (CAWS voice in B717). Gees it was hard to concentrate and troubleshoot! :eek:

In fairness to the crew - the company had taken the decision to split the QRH actions and placard them on the respective crew member's yokes, without realising the implications of the actions not being carried out sequentially.

I love the 'Capt. locking himself in the loo' quote above. In this particular case, it would have been they safest option for everyone involved!:ok:

Doves,

I do apologise if I stepped a bit harshly on your toes.

However, does any of those 70 Books (specifically those about conventional tail airliners) mention the behaviour you cited (violent pitch up upon stall)?
If so, could you maybe provide a Link ?

Because trim + elevator kept it in the stall against all natural tendencies of a conventional tail. That was what I meant when writing 'simulate a deep stall' by applying copious amounts of trim + elevator.

It is pretty safe to assume that had elevator + trim been neutral the thing would have dropped the nose upon stall. More precisely without continued trim + up elevator it wouldn't have got there in the first place it would have lowered the nose prior to that. It was only elctronics that overruled the basic flight mechanics and changed the behaviour to some extent.

Henra
 

You do not deserve that I ignore your intervention. I owe you an answer.
Please consider that to "mitigate" the problem of wingtip does not mean to eliminate it.

Anyway take a look at the following movie:

In any case the RAM Boeing 737-400 that on 6 June 2010 struck a flock of geese shortly after take off from Schiphol, if not in super stall, went dangerously close to a spin at a very low altitude and on a densely populated area.
I think something should be done because this does not recur, and because each of us reflect on how to avoid those mistakes in the future.

I don't think they were errors I think it was just incompetence. it doesn't matter how much you read if you don't have the skill or ability in the first place.

Not quite sure of the purpose in putting this movie on display. Was it to show the 737-400 has a benign stall with only a gentle wing drop and easily recoverable?

Was this a a Boeing manufacturer's movie or a company movie? And why was the flight director on display when it was not needed for navigational purposes. Typical example of automation addiction maybe?:ok:

I think the point might have been to demonstrate the tips generally stall first. Which I am pretty sure has nothing to do with this near disaster.

I think the issue here is why the pilot deviated from the rational to the irrational...

I think one possible reason, something that has been touched on previously, is that he wrongly assumed his aircrafts situation was worse than it actually was.

In the heat of the moment, of a multiple heavy bird strike, he wrongly assumed that he had had a "Sully" moment. Both engines losing thrust and unlikely to get back...

His reaction appears to be one of panick. His first thought was to get back to the airport and any procedures and rational decision making went out of the window at that point.

If he had lost both engines he would not have been able to make a turn and return to the airport. His only option probably would be to attempt a crash landing on open land or water immediately ahead.

If it had been the worst case senario he probably would have had limited options... But he still made the wrong decisions; under a moment of intense pressure he lost the plot and having set out on the wrong path continued on it.

I think that the most helpfull things to be stored in the back of his mind would have been a rehearsal of a worst case scenario on take off. This is the thought process of thinking that if you cannot save the aircraft maybe you can save people on the ground or with a lot of luck make a successful crash landing. If his mind had rehearsed the worst case then maybe, and it is just a maybe , he would have been able to make more rational choices and react to facts rather than imagined circumstances.

I think that the assumption that he was a bad pilot or did not know what the correct procedure was, in all likelyhood, not the case. It appears that he made the very human error of failing, under extreme stess, to behave rationally.

Luckily for all, the outcome was a good one. We all, at some point, will likely face a s#$t has hit the fan moment...we all hope that we will deal with that moment gracefully and rationally. To think that we are above failure is foolish. Of course, in the circumstances I doubt we will ever know the pilots perspective, but I doubt that he will happy with his performance.

Simulation only goes part of the way to prepare for high stress events...

I think I understand the decision to put the gear back down right away (though I don't think it's the first thing I would have thought of in such a scenario) and certainly appreciate that the German team cited in a similar incident used standard procedures and SOP to get their bird safely back on deck.

What I cannot get my brain around is why, with an engine failure just after lift off, the good engine wasn't at full power (this is not a propeller driven aircraft) until landing profile for whatever runway they could get to was assured. Even with the gear down, full power might have helped them get a few more feet under them as the sorted out their situation.

Once the left engine had its poultry meal, wouldn't a desire to at least get to MSA be pretty high on your list of priorities?
If yes, then why not use all of the horsepower one has to do so?

All above considered, it's hard to argue against the criticisms on training.

If SOP and Flight Manual call for a "keep it clean, climb, level off, then trouble shoot, then configure, then land" there's a training issue to address that the company ought to take a hard look at.

Another of their crews may learn the wrong thing if the "these guys made it, but there was a simpler and safer way" lessons isn't strongly emphasized.

If other crews in the airline learn the wrong lesson from this (tip cap to "hero pilot" issue) then the chance that the next unexpected poultry meal on take off ends in tears increases. :=

I'm not defending the crew here, nor do I fly airliners or fly professionally, and have not read the whole report or all the replies. Just wanted to play devils advocate a little:}:

Two ways to lower your VMC (or whatever they call it in the airline world) at full gross weight if you don't need to climb is: get the gear out (adds keeling and stability) and/or reduce thrust on good engine.

1. Maybe it's possible that the captain had another partial bird strike/or somehow other performance issue where it was safer to not add full thrust on the working engine. Or maybe the thought he did and wanted to assess.

2. Maybe he was close to entering a dangerous VMC induced spin situation and reducing the thrust was his only way to get out of it when he ran out of altitude.

3. Maybe he reduced power during final manoeuvring to position himself correctly and allow himself to bank steeper without worrying about assymetrical lift etc, especially if procedures/terrain/traffic didn't allow him to do it into the good engine.

4. Maybe he opted to prepare for an emergency landing in the flattest country on earth and extended gear for that.

5. Maybe the extended gear to add stability?

It doesn't explain all of it, but could be a possibility. I've myself had a partial engine failure in a twin and know how confusing things can get. And the one thing that will instantly solve all your problems in assymetrical flight - except the obstacle clearance one (which wasn't a factor here) - is to reduce the power on the remaining engine. That's the fix-all.

That was my thought. But I'm thinking the captain and FO are not that smart to have even realized they were in position to land to the north at about the time they completed the turn.

No, this crew was simple stupid.

We train that ALL THE TIME.....

TOGO

PR, gear up

Fly profile

Run the checks

Delcare...


This is very puzzling.

I wonder if at ANY point in the interview with the flight crew if the question:

"...WTF were you thinking..." was asked.

If so, I'd LOVE to hear the response.

Arr, the world's greatest accident investigator.

When your child last had a prang on his bike because he was riding too fast, burnt himself on something, thumped his sister and made her cry, pranged the car in the wet after having his licence for a few months, did you ask the same question? And what was the answer?

If this does turn out to be a ballsup, the fact of the matter is that the system let these two pilots get to where they got. Short of a deliberate yahoo "I'm gunna try a low level run around town on one donk with the gear down because all that ops manual stuff is rubbish", these guys probably did what they thought was the best, using all their skills. Now if they didn't have any (or little), who's fault is that?

The irony is that these guys will probably be sledged far more, because they are alive, than the Suhkoi pilots.

They got the aeroplane back on the ground in one piece despite making life very difficult for themselves. Let's learn from it instead of asking "WTF were you thinking?".

You do, but did they?

Possibly but you could say that about any human endeavour.
Unfortunately, that appears to be what they did. They had an Ops Manual which one would have hoped at least the captain had a passing familiarity with, especially concerning a engine failure on takeoff and the associated drills, on the basis of self-preservation let alone professional standards.
But it should have been a non-event. If this had happened in the USA, they'd be looking at 'reckless endangerment'.
OK, what can we learn? Don't put the gear down following an EFATO and do a low-level cruise around a big city with the other engine on a random power setting...?

I'm in the camp that would really like to know "WTF were you thinking?" so I can avoid the trap that got them in this situation, assuming that it wasn't just blind panic, lack of knowledge, low standards, poor CRM, etc.

"WTF were you doing?". I suppose that would be the first question you guys would ask the AF 447 crew as well. And the crew of just about every other prang. :hmm:

We know what they were doing - the FDR, CVR and various bits of detective work tell us that. We'd really like to know what they were thinking and why, which is the reason the BEA have assembled a team of experts to try and come up with ideas in that direction...

AdamFrish:

We're not talking about a Cessna 310, or such. A Boeing transport category jet with OEI simply does not have assymetrical flight issues at, or above, V2, and with the proper use of rudder. And, putting the gear back down defies the ground-rules of flying an OEI takeoff profile. Same with reducing thrust on the remaining engine. That is out of the question at this stage of a OEI takeoff profile.

Well, at least they made a safe landing, errors or not, its better that everybody disembarked on their own 2 feet, albeit a bit wobbly in the knees, no doubt! Does anyone know what the outcome was for the pilots?

I know what they were DOING. We all do. It's the thought-process that matters, and can help others...

So, until such time as the feds put implant a 'thinking recorder', my question remains the same...

WTF were you thinking?

Got it!?

Why go to full power on the good engine just because of an engine failure? If we imagine for one moment they did the correct thing i.e. raised the gear etc, then there's no requirement to go to full power. If they used an assumed temperature for take-off (and take it as read that they calculated that correctly) then this will allow for adequate performance in the event of an engine failure.

Of course, should you wish, full power is an option but let's not go down the incorrect road of saying engine failure automatically means full power on the good engine. If you're going to go on a low level navex around AMS with your gear down then I would agree that more power would be required than what these guys used but in a 'normal' engine failure scenario we know you can leave the power where it's set for take-off.

Surely this is where the human factors and psychologists come into it all?

It seems to me (and I've not read the report but will do on the way in to work tomorrow) that the thought processes of the PF here were of a simple 'get it home nature' and the PNF simply stepped into line because he didn't have anything better to offer.

Both crew were in an unfamiliar situation - even if they had trained for it in the simulator real life is different - they knew that they had engine damage (probably didn't remember that they had TWO engines but just had 'engine damage' going through their heads) and they knew that to land they needed to have the gear down. Maybe with all the alerts going off as well the thought was to keep the gear down to remove part of the workload for later on?

I'm not saying what they did was right, it was careless and against common sense. It was pure luck they got down in one piece but I do think that what happened on the flight deck was simple 'get it home' syndrome.

Just one other thought - could they have not gone to a higher power setting on the good engine due to noise abatement? Could that aspect of flying have been drilled into them so much that it override other aspects?

Thank you, pontius, appreciate your insight.

My "why not max power?" question had embedded in it an assumption (perhaps off the mark) that the rationale for leaving the gear down was "gonna land real soon anyway, leave it down ..." though my initial instinct would be "clean up" which apparently is close to what SOP is.

However, I seem to understand that the gents in the cockpit had begun to raise it, and reversed it in transit. Did I read that incorrectly?

Unfortunately, the geese had not filed a flight plan....

But seriously - I agree with previous postings - this should not have been a high profile incident. We are entitled to professional competence in these situations - not luck.

Well AF447 did everything wrong and everybody died. These guys did what they had to do in their opinion and everybody is ok. Sometimes sop doesn't work, remember AA DC10 crash at ORD, they followed AA sop and see what happened. These guys got it back on the ground quickly because they didn't worry about the checklist, they got it on the ground safely. Good for them. Depending on the circumstances, I might have done the same thing. I don't know the details.

TGU is one of the most dangerous airports in the world, #2, and the other airport in the mountains jets can't land at. If with all the hundreds of turkey buzzards in the valley I lost both engines of my 757 I had only one way to survive and that was stand it on a wing and land downwind otherwise you went into the hills with no chance of survival. No Hudson river there. Sometimes the pilots can handle the situation best by their talent and not just doing sop procedures. I like to follow SOP but sometimes I just can't.

Bubbers44

Where were the hills and valleys in this case to argue the throwing away of SOP's? They were LUCKY, as well as the people on the ground that they overflew. If they had followed SOP it would have probably have been a less frightening event for all involved. As was mentioned in the BEA report about AF out of Guadeloupe, "surprise" probably had a major effect here as it was not in the script. Mind you if they had seen the birds during the take off roll then they might have been expecting something!
We all know you have flown into TGU, but his was not TGU.

I find all of this talk about following or not following SOP's really worrying.

EFATO is not SOP's, its how the aircraft is certified, by not following it you are entering no mans land. Sure the aircaft can be flown with 90 degrees of bank or even inverted (Tex Johnson did it on a 707 and nearly got fired).

You are playing with peoples lives and should take that seriously, if you want to be a test pilot, do it without pax and over the sea (as long as I am not fishing there).

There are no if's and but's about EFATO, if you dont understand it ask someone to teach you.

Wrong turn while climbing
Calling the gear back down as it is going up
Throttling the remaining engine up and down
Erractic flying, left, right, up down, steep turns
Not listening to ATC vectors (at least they didn't have to take out a Jepp chart)
Shuting down the dead engine after 4 minutes
Landing at 173kt with flaps 5 instead of the normal flap 15 engine out procedure (they actually left the flaps at take off setting just like the gear)

Obviously they got scared and wanted to get back down to the ground ASAP.

No, they turned what should have been a non-event into a near disaster. It was "got onto the ground" in the most un-safe manner imaginable!

If they'd followed SOPs and flown a standard EO profile, we wouldn't be talking about it now.

Yes, there are times when you have to "think outside the box". A simple, contained engine failure is not one of them. Your performance is predicated upon a) having the gear up and b) at least the power you took off with on the other engine(s); anything else and it's lap-of-the-gods stuff.

It's a good idea to have a "plan B" (and C, D, E...) and to discuss or at least think about what you might do in certain scenarios before you commit to the sky. In the case we're looking at now it really seems like they were making it up as they went along and only through sheer good fortune got it back on the airfield in one piece.

At the point of failure, the aeroplane had the capability to climb to a safe altitude, fly an arrival, execute a missed approach and divert to a safe landing at an alternate airfield. This is what it is certified to do. What possessed the crew on this particular day to go way outside the envelope I'd really like to know... They had two opportunities to get straight back on the ground not long after takeoff but didn't take them, so it can't have been a desperate urge to return to the Earth's surface driving it. As I've said before, what were they thinking?

737ng.... Could you provide a similar sequential critique of the A.F. crews performance?...as this produced a different outcome.
I presently despair that neither crew were following SOPs or indeed most forms of basic airman-ship or any form of present day CRM which I read so much about.
If asking WTF were you thinking about?... regarding any incident I might have been involved in..this would by its hostile implication stun me into total silence and a 2,000yard stare as an Sop response.
Probably not the best opening accident investigation question in a "We are all in this together" age which I observe we are not.:ok:

4080
 

I wouldn't call it sequential criticism, just trying to analyse the facts; I think we all know that chair flying, or even sim training is one thing, but real life emergencies are something else. This could explain the added stress, and the fact that a pilot would have basic human reactions,(pulling up instead of down, not run through the checklist properly even though you know it by heart, etc) instead of a "well trained" pilot's reactions.

About AF447... Well we all agree that they messed up BIG TIME, but it was a dark black night, above the ocean, lots of alarms, unreliable instruments (at least what they thought) plus high altitude stalls are said to be harder to recover from usual stalls (I didn't try, and don't want to).

I actually think if one of the other pilots was PIC, they might not have crashed. Bonin kept pulling up, up, and up on that stick. On the CVR he even admits "we're descending but I've been pulling back for a while" and Captain Dubois tells him "no, no don't pull up". The PNF, from his words on the transcript, seemed to have grasped the situation a little better. But unfortunately, he did not take over command. And I can understand that.

What I really find incredible though, is NOT not being able to break the stall, (even though they had 4 minutes to do it), but GETTING INTO that stall in the first place. Bonin should have known better than recklessly pulling on the stick and climbing 3000 feet in a few seconds when they were already very close to max cruise altitude for their given weight, and the air temperature.

And, even more unbelievable, as you can read on the transcript, even though his colleague expresses his worries saying "we're passing 10000 feet", and then saying "damn it, we're going to hit, I can't believe it" Bonin replies "but what is happening here", proof he still had no clue what was going on, even though the altimeter must have been unwinding down at 10000ft/mn!!!!!

All the while Captain Dubois is sitting behind, watching them, saying a couple words and not doing much.

Once again, my personal analysis of the situation, we'll wait for the human factors specialists and what they have to say about that.

Over the decades, I have seen several episodes in which I found more respect for the airplane than for the PIC. Reading through this thread, I add it to my list.