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-   -   Distracted crew let Q400 descend towards terrain (https://www.pprune.org/rumours-news/488334-distracted-crew-let-q400-descend-towards-terrain.html)

Windsprite 26th Jun 2012 12:29

Hikoushi Post
 
Now that is the kind of post that helps aviators on this site to enhance their knowledge using the experience of others. Learn from the mistakes of others who are kind enough to share it with you. Do not insist on making your own!!:D

Capt Pit Bull 26th Jun 2012 15:32

OK...

1. Change of data source causes mode deactivation.
2. loss of mode causes unintended flight path

It seems the crew were distracted by the abnormal, so the flight path was not monitored, and therefore deviation not spotted until GPWS. Obviously I think the CRM fell apart in regards to this.

The report also refers to them not noticing the mode deactivation or monitoring the FMAs. Now, is it being suggested that the mode deactivation should have been spotted as a matter of routine scan? if so, I disagree. Yes, in general routine scanning should pick up mode changes, I don't dispute that, but in this case the mode change shouldn't have come as a surprise.

I'm not familiar with the Q400, either it's avionics or checklists, so the following terminology may be wrong, but the gist of what Im saying should be valid. Comparable aircraft I have flown have had similar behaviours. I.e. Changing data sources might result in a mode change. Thus, changing a data source is an event of equal gravity to making a flight mode selection.

So it should have a thought process to match:
What modes have I got?
What should happen when I make these selections?
(make the selections)
Are the modes as I expected? (if not, why?)
Is the other pilots mental model of the current modes the same as mine? If not, which (if either!) of us is right?

In this case the very act of reaching for the air data selector should have triggered the knowledge that it would disarm the alt capture, and a wise PNF would verbalise that knowledge IMHO. 'this will kill your vertical modes' or similar.

So to me this doesn't just speak of a crm breakdown, but also weak initial tech training and/or poor recurrent training. Surely an ADC failure should be part of the recurrent sim training?

Please note I'm pointing the finger less at the crew than the training, but also at the industry in general.

fade to grey 26th Jun 2012 15:34

PAX,
You clearly state you are a passenger so the only thing you are qualified to comment on is seat comfort.

I'm not attacking Flybe or their pilots (I know a few), but for operational or technical reasons they do pop up alot on AAIB. The one that almost hit the mast at aberdeen, the one that scrapped the tail.... etc etc. Fact is the Q400 is in there often.

Nor would I suggest it couldn't happen to me, it can happen to anyone at anytime.Wasn't it the captain of the titanic who stated the day before it sunk he had never had any incidents in 40 years.

Keep telling myself the mantra aviate-navigate-communicate all the time, and that basic premise stands good.Do not be distracted.

Richard Taylor 26th Jun 2012 16:07

"I'm not attacking Flybe or their pilots (I know a few), but for operational or technical reasons they do pop up alot on AAIB. The one that almost hit the mast at aberdeen, the one that scrapped the tail.... etc etc. Fact is the Q400 is in there often."

If you are referring to the incident that I think you are referring to, that was i. Brymon, ii. a DHC8-300 & iii. 1998.

Not aware of any other instance of a plane approaching Aberdeen coming close to that mast, be it Flybe or anyone else.

flydive1 26th Jun 2012 18:05


Originally Posted by fade to grey (Post 7263244)
Wasn't it the captain of the titanic who stated the day before it sunk he had never had any incidents in 40 years.

Not strictly true

2EggOmelette 27th Jun 2012 15:52

Fade to Grey.

Aviate, Navigate, communicate.
Dead right.

But please mate, that comment to Pax was wrong. That type of comment does none of us any good. So what if he's a spotter. He has an interest, and going by past comments of his he does have a clue. If not, at least he asks. The least any instructor would ask :=

2EggOmelette 27th Jun 2012 18:50

Well said Jazz :ok:

fade to grey 27th Jun 2012 20:40

Jazz - i don't see that your point relates to me, that's up to BALPA if they want opinions from passengers,whoever.

Adam - yeah, fair enough I was a bit harsh. But PAXboy accuses me of a 'snap judgement' , I'm not judging anyone, but I maintain thats hours/age is generally a reliable indicator of background.

Everyone's a bit touchy round here.

2EggOmelette 27th Jun 2012 21:48

yeah, fair call mate. But just remember, everyone is allowed their opinion. Snap judgement aside, it is no less than ours in retrospect. Our opinion is based from experience. Some know more, others less. most if not all are relevant, but the jems are from those from the outside. I always listen to the pax, it is those who we serve no?

bubbers44 28th Jun 2012 00:04

For those that missed it take a look at post 18. That is probably the hardest thing for the 300 hr guys to do, drop down a notch or two in automation even if it means hand flying to make the job simpler. Too much programing and monitoring programing at low altitude can really screw up your situational awareness with a last minute runway change.

Squawking PAX 28th Jun 2012 02:58

As an SLF I have read PPRuNe for years but never commented - not my place to get in the way perhaps. However, this time.

OK, this forum does have its share of un-informed or un-thought through comments often from people who are (hopefully) not in the industry and at best may only be qualified to evaluate seat comfort.

However not all PAX are telephone sanitisers, some are well qualified to have opinions on or even insights into the issues discussed. Some work with technology and with the use of technology by people at similar levels to you. Some may have friends and family in the industry. Some will be well informed across the training and resource management issues you face. Some may actually have useful input.

My own interests involve training people to use (and understand) the increasingly complex "labour saving technologies" that we find in science and industry today. This is of real significance to the airline industry today with workload and knowledge/understanding issues sometimes causing it all to hit the fan when the old swiss cheese starts to wobble.

I do wonder what you all think of the automation of flying today where as systems become more simple on the outside they may become far more complex on the inside making it harder to understand what the plane is doing or complaining about now. And we certainly have had some very tragic outcomes as a result.

Is it getting harder for under-experienced or under-trained pilots to cope when push comes to shove?

Unfortunately flying is an industry which is seldom measured by its daily successes of which there are millions but by its few failures.

Anyway, for those of you who are doing the "good work", thank you and keep it up.:ok:

Sunnyjohn 28th Jun 2012 10:36

Well done, Jazz Hands
 
- you just made one of the threads in Jet Blast.


If you think passengers know naff all, that's fine, but you're walking on thin ice if you then start leveraging those same ill-informed views to push your own agenda.

davedek 28th Jun 2012 11:54

(Taken from the report on page 1):

"It adds that the crew did not follow standard procedures after the terrain warning."

What is the story here?? Seems to me like this could be a FAR bigger issue... anyone could make the initial mistake - but did they not respond properly to the gpws?

fade to grey 28th Jun 2012 17:39

Squawking PAX,
I'll give you my pence worth. Reliance on automatics has been around for years, this is the way modern airliners are flown.

I think,maybe, too much fuss is made about it. To be honest there are alot of occasions where you don't want to hand fly anyway - departing LHR ? far too much happening, above 10000 - company doesn't allow it . Descending into XXX after 8 hr flight - too knackered now. Ok , departing xxx - er, no high terrain, and dodgy ATC.....To be honest I don't need a large proportion of my capacity taken up with raw data/hand flying, I have other things to do, even moreso from LHS. We must face the facts that we are not really 'pilots' in the conventional sense anymore.Wanna hand fly ,go hire an extra at the weekend.

Now that's not to say I don't want to stay current in hand flying, but that's mainly for my own reassurance - I've found when people don't do it for a while they become fearful of cocking up. Not really for the 'what ifs' because to be honest, the boeing I fly has 3 autopilots and not once have I been in the boat of having none serviceable in 9 years on type.That's not to say it would never happen but into the realms of low probability I think.

Slightly off track, but IIRC the MEL says you can dispatch with no A/Ps, but with my (last) company ban on hand flying above 10k it ain't gonna happen is it ?

Clandestino 28th Jun 2012 19:29

Give the fellows that put together the assembly of parts collectively known as Q400 Collier trophy, for their lovechild has successfully turned "You fly like an autopilot" from a compliment to an insult.

I'm not talking about that particular (soon to be two year old) incident, just the "normal" everyday operation.

bubbers44 28th Jun 2012 21:57

If you are as comfortable hand flying as programming an autopilot, sure let the autopilot do it. If you are uncomfortable disconnecting the autopilot and autothrottle then it is time to do some hand flying so you are. Do it where you can get up to speed without getting behind the aircraft however. Not in a terminal area.

Burpbot 29th Jun 2012 01:08

As a reader of this forum for years, it never fails to amuse me the crap spoken! I liken it to reading a paper, if you have ever been involved in a story you will know how untrue a newspaper article reflects it! Prune is similar it's become a joke! Shame as used to be a Good portal to share, but from now on I don't think I will bother anymore as its become a joke! For the record airline captain nearly 20 years online!, I met danny once and thought good on you! Where did the ideals go? Shame!!!!

fade to grey 29th Jun 2012 07:49

Burpbot - don't believe it . Trolling ?

738 - You can't just 'do it' - I'll say it again company SOPs don't allow it. Are you familiar with the idea of SOPs ?And the rest is not bla bla bla, the rest is what will get you nicked on the QAR.

I am somewhat concerned about your slapdash approach, mate.

I hear of another airline where there are no hand flying limits, so some young chap decided to fly all the way to XXX by hand. Bloody great idea (not), like I want to spend 70 % of my time monitoring him

bubbers44 30th Jun 2012 00:52

B738 driver: I agree with you all the way. Our major airline had no sop's about handflying. The only airlines that would need those SOP's would be for pilots that couldn't hand fly. Needing an autopilot to fly your aircraft is scary. It should be a workload reliever, not a substitute for a competent pilot.

90 % of my approaches were hand flown because the last 6 years I flew into TGU in Honduras and you had to hand fly. Letting automation fly your airplane because it is safer in VMC conditions means you are not up to the task and should sharpen your hand flying skills. SOP's for automation only airlines probably hire low time pilots out of Embry Riddle that know how to program a computer but can't hand fly well.

Thank God the older airlines still have pilots that can fly without computers. Most haven't hired since 911. I saw the last group get furloughed two weeks after 911 and they aren't back yet. Sad.

Island-Flyer 30th Jun 2012 04:06

I imagine the Q400 has a far superior autopilot but the DHC-8-100/200 autopilot has so many restrictions for its use we were required to hand fly 80% of our approaches.

fade to grey 30th Jun 2012 09:29

No, you are absolutely right, you are not my mate. Consider mate withdrawn UFN.

I can't be arsed to battle with either the spotters or the self obsessed ego monsters prevalent on here

haughtney1 30th Jun 2012 10:39


It seems that there is always a "good reason" not to hand fly. Although I agree that there are places and times to practice raw data flying, I realize that for some pilots it takes some effort to disconnect (click click A/P, click click A/T, FD's off) and there you go.

The location is not right (i.e London TMA), the weather is not good, the pilots are tired, the experience split between pilots is too big, company SOP's, etc...

The fact is: just do it. And make it mandatory for yourself once per day (if short haul),once per week (if long haul), up & down from ground to FL100.
Late into this thread, but after reading this load of tripe, I'm wondering which "big" airline you work for? (although something sounding similar to Mikey Air is probably where you reside)

It may surprise you sir, that the very things you suggest as being required and necessary..or to use your Nike inspired phrase "just do it" would put the collective arses of everyone where I work in a rather large sling thanks to the PCMIA card. Not only is manual flight frowned apon, it is actively discouraged and mandated against i.e. there are no practice approaches..FD off AT disconnected with 400 or so paying punters in the back.
Manual flight where it is appropriate and required, but the maximum use of automation at all times.
If this doesn't sit well with you then I would suggest you have failed to understand that there are plenty of operators where we might get 3-4 sectors a month, and the vast majority of landings are after 10 or more hours in the cruise, I for one won't be disconnecting until 1000' AGL or reciept of landing clearance anytime soon, my manual handling comes along once every 3 months in the sim.
Honestly...ego monsters indeed!

bubbers44 30th Jun 2012 23:44

I think I see what is the future. No handflown approaches because the pilots aren't as good as the autopilots. Kind of sad, isn't it? Didn't use to be that way when we had real pilots. I am glad I am done. Most young pilots probably agree.

Dream Land 1st Jul 2012 00:01

I don't necessarily agree with that statement, there are some very good sticks out there, but company SOP's, QAR monitoring, along with much more traffic and different ATC procedures don't always make it a great environment for hand flying.

bubbers44 1st Jul 2012 00:44

What has hand flying made so difficult in the last 9 years? It wasn't then.

bubbers44 1st Jul 2012 00:55

I guess I am just in a lost bunch of pilots that retired at 60 who flew til they listen to how the new guys do it. If the autopilot doesn't work, don't blame me.

Capn Bloggs 1st Jul 2012 01:16

Oh come on, Haughtney1. Next you'll be saying "AF447 was just one of those things that happens, get over it".

Canned handflying in the sim once in a while is so far removed from the skills you may need, like that A330 crew needed, that it is basically a WOFTAM.

haughtney1 1st Jul 2012 04:10


Oh come on, Haughtney1. Next you'll be saying "AF447 was just one of those things that happens, get over it".

Canned handflying in the sim once in a while is so far removed from the skills you may need, like that A330 crew needed, that it is basically a WOFTAM.
Nope Bloggsy I'd never in a million years say that, I'm pretty sure that if the AF447 had reverted to basic pitch and power, theyd be alive today. A management bean-counter on the other hand would most likely say "its just the cost of doing business"
As for canned hand flying, well, thats how my outfit want it done:ugh:
Of course the worm is S L O W L Y turning, the sim flying is a direct result of AF447 and other less serious incidents, but the flight Ops management where I work have deemed that it be done this way.

COM Cleaner 1st Jul 2012 15:09

automation policy
 
hey Captain Bloggs,

Doesn't your mob have the same automation policy as haughtney1 - avoid manual flight at all costs? :eek:

gatbusdriver 1st Jul 2012 20:55

Why are you giving haughtney1 a hard time? He is right in what he says. If I was a virgin 340 pilot getting upto 2 landings a month I would not think that practising my hand flying on the line was a good idea, especially in busy TMA's at the end of a long duty day. If I worked for the likes of Emirates I would also think it was a bad idea due to FDM and SOP's. Improve your hand flying with an extra or a Cessna in these situations.

The AF accident did not happen because of a lack of hand flying on every other sector. It happened because the wrong pilot was in the wrong seat at the wrong time. There was a failure to recognise the stall and carry out recovery on behalf of the handling pilot and PM was unaware of the inputs of PF due to side stick.

bubbers44 1st Jul 2012 21:19

That means one pilot could not hand fly and the senior copilot couldn't either. If he could he would have taken over if he had the confidence to do so but he didn't. That is why everybody died.

Chuck Ellsworth 1st Jul 2012 22:14

Hand flying?

Using raw data for situational awareness?

I was really bored today and decided to read this thread.....now I am no longer bored I am afraid.

Knowing there might be pilots out there flying for some airlines that consider hand flying to be black magic that is to dangerous to try except in the Sim occasionally and is against their SOP's is reason for me to feel fear....

bubbers44 1st Jul 2012 22:25

No matter what your airline tells you, if you never handfly, you won't disconnect the autopilot. If it disconnects itself you are hand flying but have to deal with hand flying. Your choice.

Capn Bloggs 2nd Jul 2012 01:06


If I was a virgin 340 pilot getting upto 2 landings a month I would not think that practising my hand flying on the line was a good idea
Strange. I talked to a Virgin A340 pilot last year and he said there was no discouragement from handflying or for that matter getting rid of the FD and autothrust.


Originally Posted by COM cleaner
Doesn't your mob have the same automation policy as haughtney1 - avoid manual flight at all costs?

It does; my take on Haughtney's post was that he supports his compnay's policy.


The AF accident did not happen because of a lack of hand flying on every other sector. It happened because the wrong pilot was in the wrong seat at the wrong time. There was a failure to recognise the stall and carry out recovery on behalf of the handling pilot and PM was unaware of the inputs of PF due to side stick.
Absolute rubbish. Had the PF been practiced at hand flying at high altitude he in all probability would not have pulled the nose up so much and stalled the thing in the first place! "Hmm, this is strange, I'm hand flying, the power hasn't changed and we're climbing for the moon, better lower the nose a bit so she doesn't stall..."

The aeroplane was stalled, pure and simple, and the three pilots were so unskilled/practiced at scanning all the instruments, so unpracticed at taking in all the information they had in front of them, were so stunned by what was going on, that they sat there virtually doing nothing because they couldn't work it out. I agree that some whacko Airbus design features didn't help.

Every second you get practicing your IF scan ASI/VS/Altimeter/Attitude, actually looking at and feeling the response from your (even minor) control inputs when hand flying, will help you identify a completely odd-ball, totally weird situation and recover from it.

Machinbird 2nd Jul 2012 02:12


Originally Posted by gatbusdriver
The AF accident did not happen because of a lack of hand flying on every other sector. It happened because the wrong pilot was in the wrong seat at the wrong time. There was a failure to recognise the stall and carry out recovery on behalf of the handling pilot and PM was unaware of the inputs of PF due to side stick.

gatbusdriver, do you care to offer an opinion as to why PF was unable to hack the program? What was missing from his training or background? The retrospective view of "He didn't hack the program." really doesn't tell us what the problem was.

The Ancient Geek 2nd Jul 2012 09:00

Please can we get this thread back on topic.

The incident concerned has nothing to do with hand flying.
They lost situational awareness while distracted by a problem, they should have rejected the approach and taken their time to sort it out in the pattern.

haughtney1 2nd Jul 2012 09:11

A few points of interest..rebuttal if you will.


my take on Haughtney's post was that he supports his compnay's policy.
Then your take Capt is incorrect, I neither support nor am vehemently opposed to the policy, I do however understand the rational and the mindset behind such a policy.
Do I think it causes an erosion in flying skill? yes most definitely, do I think flt Ops managers believe this as well? for the most part yes, but statisically speaking, the various regulators, risk managers, manufacturers and guys who run company SMS and flight safety programmes consisently produce data that drive these policies in the first place.
As a matter of fact I hand-flew an approach into an Australian airport a little while back after getting back to my seat and feeling well rested, it was day VMC and the gusty crosswind was near my company limit, I felt it was safer and more appropriate than using automation and disconnecting at 1000 AGL with a handlful of aeroplane.

738 Drvr


You completely miss the point here. But that's ok, whatever works for you. In my company raw data / hand flying flying is not encouraged either, and nowhere in the SOP's will you find any recommandation to practise FD off/ AT disconnected approaches.

It does not mean that pilots are not responsible to maintain their flying skills. Hand flying is not to be practised in the sim (poor saoul, I wish I never heard that), but is on the line. It does not matter if you have 400 or 200 or 2 passengers in the back, they would still expect the pilots able to handle a non normal when the situation arises. It does not matter if you have 1, 2 or 3 autopilots, automation is dangerous when used as a replacement of your basic stick and rudder skills. The AF447 is just a one of the examples, but there are many more out there.
Actually, I get the point entirely, the difference is, if I disconnect an A/T, or turn off a FD without a bloody good reason, I will find myself in the chief pilots office for coffee and dates in fairly short order, and if I trott out the line " I was just doing it to maintain my profficiency" I will be shown the door in fairly short order.
Now can I fly a rate 1 turn and not gain or lose 50 feet? yep, I certainly can, can I manually fly a CAT 1 ILS in raw data to minimums? yes I can do that too, I use bullet proof techniques that equate to flying the jet by numbers, in fact thats what I base my whole operation on, pitch and power..simples.


Absolute rubbish. Had the PF been practiced at hand flying at high altitude he in all probability would not have pulled the nose up so much and stalled the thing in the first place!
Bloggsy, one last thing, if your company lets you hand-fly up at high alt, more power to you, if I tried that, it would be do not pass go, do not collect 200 whatevers and here is your resignation letter to sign.

Yellow Son 2nd Jul 2012 09:42

Experience?
 
'Hours/age is an indicator' says Fade To Gray. Yes, but it's not a totally precise tool. When I was in my early 40s I had 3000 hours, so perhaps you might consider me inexperienced. But nearly all of that had been military, half of it intensive, short, teaching sorties. Even on 4-jets we had the luxury of adding a couple of extra approaches at the end of most trips. It's surely not too simplistic to say that time spent on takeoffs and landings contributes more to useful experience than flying S&L at FL 300. That's not meant to undervalue the undoubted competence of the 15,000 hour airline pilot, but don't let's pretend that a man with 'only' 3,000 hours is necessarily a newbie.

fade to grey 2nd Jul 2012 11:15

No, fair point, yellow son . I know with the current lack of flying in the mil some of the FJ boys are getting 100 hrs a year ?

I think I can summarise, that we would all like to hand fly but some SOPs don't allow much of it .

I don't think AF447 had much to do with hand flying - more a failure to interpret and act on what the instruments were saying. I am sure they could have manipulated the AP earlier to achieve a favourable outcome.

I know in a previous life a capt who got a telling off as the FO felt he was being forced to fly a visual when he didn't want to to...I never pressurised anyone, if they fancied a go fair enough, if not fair enough.

I certainly don't by into the machismo (seen elsewhere on here) that basically consists of " you 're not hand flying, because you can't", that amounts to little more than bullying really.

Yellow Son 2nd Jul 2012 11:58

Flying Experience
 
We grumbled on the squadron that Flight Safety was being compromised when we had a temporay restriction to 15 hours a month. If it's down to 100 hours a year, then I'm with Charlie Brown - Good Grief! Especially given that time on Ops has limited training value. But that's probably a topic for a whole other thread (I expect it has been already). I'm just thankful I'm not having to put up with that myself these days.

As an aside, I had an amusing moment while converting to the G1000 - forced on me by my Flying Club. During my check ride I was inflicted with the predictable 'graceful degradation'; during the debrief, the checker commented that I seemed to be more at home the fewer systems that were available. I had to admit that the final 'everything failed' scenario was the closst to the avionics fits I had been used to during my 3000 hours in the RAF! Not sure what lessons to draw from that - certainly nothing relevant to this thread - but it tickled me anyhow.


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