Distracted crew let Q400 descend towards terrain
 

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Distracted crew let Q400 descend towards terrain

By: David Kaminski-Morrow London

Pilots of a Flybe Bombardier Q400 allowed the aircraft to drift below its glidepath after becoming distracted by an electrical failure that had affected the captain's displays.

It descended to about 700ft (210m) above terrain, while still 8nm (15km) from the runway, before the ground-proximity warning system ordered the crew to pull up.

The Q400 had been conducting an instrument landing system approach to Exeter's Runway 26 on 11 September 2010. Its autopilot was engaged and the aircraft had been descending to a selected altitude of 2,600ft.

At about 3,300ft the engine display indicated a processor failure. While the first officer's primary displays remained normal, the captain's showed absent speed bugs and minimum descent altitude setting.

The captain tried various techniques to restore the display, including switching the air-data computer source before reverting to the original when this failed to have an effect. However, the UK Air Accidents Investigation Branch says that this reversion, by design, cancelled all previously-selected flight-director modes - including the altitude selection. This deactivation "went unnoticed" by the crew, it adds, and the effect was to allow the Q400 to descend through its cleared level.

"While attempting to resolve an unfamiliar failure which had resulted in unexpected cockpit effects, both pilots became distracted from the primary roles of flying and monitoring the aircraft," it says.

Having failed to capture the cleared altitude the aircraft continued to descend until the ground-proximity warning system issued a terrain alert - prompting the two pilots to look up - followed a few seconds later by a "pull up" command.

There had been no action to correct the flightpath before the warning, suggesting the pilots were "not aware of the extent of the deviation" and were not monitoring the Q400's track or its flight-mode annunciator, says the AAIB.

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

The AAIB points out it has investigated two previous incidents involving Flybe Q400s, in which the aircraft descended below their cleared level during approach owing to inappropriate mode selection and inadequate annunciator monitoring.

Flybe, which gave the pilots additional training before returning them to duty, has since introduced a new flight-operations monitoring programme involving observers in the cockpit.

Any similarity to Tristar Eastern 401 in Everglades on Dec 29th 1972?
But with a little difference: "Saint GPWS!!!"

1969
 

Or SAS 1969 LAX: Scandinavian Airlines Flight 933 - Wikipedia, the free encyclopedia

In the Q400 it doesn't take a processor failure to have you descending towards terra firma.
A single click on the pitch wheel while on the glideslope does, if unnoticed, the same.
Been there, done that... :uhoh:

Somebody forgot FTFA.

New story, old news.

Distracted crew let Q400 descend towards terrain
 

HELLO!:
"DOES ANYBODY HAVE CONTROL?"
(while passengers seating in 0A and 0B quarrel?)

http://www.pprune.org/rumours-news/4...-deck-row.html
https://www.newscore.com/


Incident: Flybe DH8D at Waterford on Jun 5th 2012, runway excursion during backtracking

http://www.dailyrecord.co.uk/2012/06...6908-23881832/

if you look at the AAIB bulletins, hardly a month goes past without a Flybe DHC8 getting a mention.
I,ve no idea if this is because of the high volume of flights,fatigue from the schedule or the generally low crew experience.

@ fade to grey

At least the incidents are reported - unlike many cases in the Medical or Shipping professions. I think I'm still proud my employer (not BE) has an "open" policy and any incidents are reported.

We all practice for the major failures in the sim, this goes to show that even a small component failure, in itself not critical, can lead to another of the holes in the "Swiss Cheese" to line up.

It's a lesson that should be learned by all professional pilots, don't be seduced by the "it won't happen to me" syndrome...... however good you are, it just might!

fade to grey

Generally low crew experience? I don't think that was a factor in this case. There's a hell of alot less experience in another major UK operator which we all know about, and Snigs is correct, you are only one flight away from your next incident so if we think it won't happen to us then think again.

The experience levels on the Q400 are currently high. This could have happened to the greatest 'ace' that contributes to pprune considering the machine that was involved - also what not appears to be mentioned is that I believe it was a CAVOK visual approach

Ah, yes.

I believe those CAVOK approaches can be tricky....

Tourist,

Perhaps a more useful description would be "seductive" - many a good driver has been sucked in because "it was only a visual approach"!

Wow, you are so, so kind! Now if that happens in the developing world, then all hell breaks loose with all kinds of insinuations and innuendos about competency and discipline.

A more appropriate response which is unfortunately not trained as often as it should be in our modern, automation-dependent world would be the old "click-click, click-click". Those of us from before the MPL / G1000 generation learned to fly on aircraft with no "bugs" on the airspeed indicators; most of us learned to fly an ILS raw-data with a pair of crosshairs or maybe an HSI in more recent times. When flight directors, FMAs, speed and heading bugs etc go kittywompus on us we should still be able to "step down" the automation and handfly comfortably on basics. A missed approach is another safe option. It seems like these skills are discouraged in most SOPs and training departments these days, and that is a disservice to pilots who could benefit from maintaining those skills, such as this situation.

Have the chart in front of you. If you lose your G/S or ALT SEL on your FMA, turn it all off and fly the airplane like it was a very fast Seminole. This is how it should be trained and skill should be mandated. We have to log autolands to maintain currency in my company; why not mandate log at least one raw-data fully hand-flown approach (in VMC even!) every 90 days? Probably get laughed out of the building to bring that one up to a training department anywhere in the world these days, which is sad. If that were trained to proficiency, instinct, and recency to the extent autoflight is, these kind of incidents would decrease.

Never going to happen. Oh well, starting to show my age, I guess!:eek:

Great post, hikoushi. :D

Evidence to support FTOs or TRTOs not following the EASA/JAA syllabus? Or just an ill informed two pennies worth?

As for the airline in question, my understanding is the autopilot on the dash 8 is so unuser friendly, full of latent errors, that pilots hand fly more often than most.

But as a general case for modern aviation, I see your point.

A very nice video. It's interesting to see it was filmed in 97 and yet the same message is having to be consistently repeated. Every SESMA review carries the same messages, along with recurrent check debriefs/learning points to the respective fleets.

I still have my copy of "What's it doing now?" issued by my company. It highlighted the differences in errors due to lower SA as a result of flying the glass cockpit version of the 737 as opposed to the trabbie (200). Those in the steam powered version had far higher levels of SA. But the technology was supposed to make it the other way round. Still to this day aircraft automatics get miss managed, due to over dependence at critical times, and less critical. Pilots are more out of the loop than ever due to 'bean counter style' Flt ops/safety policies implemented by some training regimes and the likes. Fancier versions of NOTECHS have been issued since, yet the training, whilst invaluable, gets left behind by back side covering policies that aim to ridicule pilots for making mistakes when the automatics were available. Yet when distractions with automatics engaged lead to Loss of SA and resultant errors, more blame is placed on pilots for forgetting to FLY THE AIRCRAFT. An interesting modern day conundrum, but one that does little for safety.
Ultimately it is incumbent on companies and individual to keep skill levels up and awareness at all times. Appropriate support for development of these skills is vital. Without appropriate policies and training support, AIRMANSHIP IS LOST.

I have read with interest the thread where line captains complain about having to 'train/babysit' new ab-initio pilots on the line. The best place for them to hone their skills is on the aircraft! They require the right supporting manager(CAPTAIN) to help guide them. In time they become 'in tune' with the aircraft and far better pilots. The simulator is no airplane! But then a C152 or PA 34 is no dash 8/ airbus or 737!
More emphasis these days is placed at the ab-initio level on not being heads down reprogramming the box at bust times! ANC and PPP are the keys for priorities. But as one young lad a few years back remarked, post event, when I asked him what colour the van beside the runway was ( you have already guessed where his attention was) "I was so used to doing it on Flt sim when I was getting ready to do my training, I wanted to prove I could do it in the real thing". He learnt a big lesson that day, so did I.

Tyreplug - Are you insane ? the Captain had 3000hrs total, 1500 on type and was 44 years old. I don't consider that alot of experience to be honest, and the age against hours indicates a 'career changer'.

I think low experience combined with a demanding crappy TP, multi sector hard fatiguing days are the main reasons the AAIB bulletin should be renamed 'Flybe monthly'.

Arctic , I know who you mean, but the FOs may be fresh off the money making schemes but the Capts have more than 3000 hrs ?...... Actually I don't know if you are talking about the low cost harp boys.

Calm down, I know this sort of thing happens to anyone, it's just it all seems to happen to Flybe more....

At least they keep their jobs and receive assistive training.
My old company would have carried out a full and thorough investigation and then sacked them!

When we all learned instruments, our instructors (or at least my instructor) always told us to keep the "next two things" in mind. I remember practicing nonprecision approaches and always being asked "what now, and what next?" over and over again. He'd pull the chart out off my yoke clip and expect a response like "7 miles to go to the VOR, out of 3100 descending to 2200, level then configure at 2 DME, then next altitude 1400 next course 274, right crosswind". Always know the next two things that are going to happen. This is your PRIMARY situational awareness tool; extraneous avionics are SECONDARY to it, ALWAYS.

As we get into larger, better equipped aircraft with glass, FMS, GPS, moving maps, VNAV, etc and fly longer routes with less-frequent landings, we naturally start to lean on the automation to tell us these "next two things". Initial and recurrent training in the airline world assumes tacitly that professional pilots do not need to be taught these basic airmanship skills; you are EXPECTED to bring that to the plate with you from jumpstreet, day 1. This is as it should be. However, over the years the natural encroachment of automation dependency (or shall I say unconscious automation laziness..?) that most of us at least occasionally experience will erode those sharp thinking processes. THAT is the thing that in my humble opinion is NOT adequately addressed in most training. Maintenance of those truly fundamental skills of airmanship which can all too easily be overlooked by the fact that the purple line very rarely fails during a simulator check.

A flight director, autopilot, etc is a CONVENIENCE item, fundamentally. It increases safety when it 1. reduces fatigue and 2. is FULLY under the pilot's control, allowing an increased sense of situational awareness by attending to the basic task of flying while allowing the pilot to monitor a more relaxed "big picture". If it fails to do either one of those things, it becomes a liability and should be instinctually and instantly disregarded. By always maintaining that same thought pattern of the "next two things", monitoring the raw data underneath the automation, this instinctive "step down" to basics is a complete nonissue. We must simply ALWAYS, proactively keep our mind engaged with the airplane, whether flying with hands on the yoke or with the autoflight system.

It's been a long time since I've been anywhere near a Dash, but as a former TRI and captain on 3 out of 4 models of the Crash-8 for a few thousand hours on type I can tell you that these basics hold as true for that aircraft as a 172, as well as for the jet types I've had the pleasure of enjoying subsequently. The hypnotic effect of automation complacency is equally destructive to basic airmanship and situational awareness in all of the above, as well.

"But for the grace of God, there go I". This kind of incident could happen to ANY of us in a moment of unaware fixation. Anyone who disagrees with that statement is either wrong, or truly much smarter than myself and 90% of the people I have flown with in any capacity in my entire career. Fly safe and remember the "next two things".

SLF here.
fade to greyThat is a real snap judgement on someone that you do not know. PERHAPS the numbers tell of a person who realised that the 'glamorous' long haul was costing family life? Perhaps someone decided to work short haul local to be more human?

PAXboy:

They no longer log long-haul hours?

Hmm! 46 years 'experience' as a passenger but no knowledge of the industry?

Was that 3000 hours as Captain or total flying hours?

We really need to drop this topic of 'experience'. 3000hrs is ample for the job and sufficient for a 737/AB command. Add in 1500 on type and I would suggest this Cpt was just fine on experience.

Read hikoushi's post - it could happen to a 30,000 hr pilot. No, it shouldn't, but it can.

The classic example was Eastern 401. A crew fixated upon a warning light whilst the autopilot flew the aircraft into the ground. The captain had just under 30,000hr .

fade to grey
Did you see the First Choice 767 damage photos contained in the AAIB bulletin of the previous month? 14,000 hr skippers can make mistakes too. I take issue with the crass "flybe monthly" comment; 2 out of 4 events reported in the last few months were due to technical faults rather than crew error/low experience.

I am sure the MPL will improve things:eek:

And the can of worms is opened.

Or more precisely it didn't.

hikushi post
 

hikoushi,
As a turboprop to heavy jet pilot myself, I would like to to compliment you on a post which is among the best I have ever read on Pprune.

Serenity ..my post referred to EA 401

Eastern wiseguy is correct in that the Autopilot on EA 401 had disconnected . Due to a difference in the breakout forces between the Captain's Yoke and the F/O's yoke, on the F/O's side the light which indicated autopilot engagement and altitude hold remained lit even though the autopilot had been inadvertently disconnected by a nudge from the Captain.

Nowhere in my instrument training because we had no autopilot did it say to monitor the descent. It said do it to the next altitude. I know the new guys use automation because of their expeience level so tend to rely on it more than us old guys. Hope they figure it out before the next event. The next one might be like Buffalo if they don't get their act together. Just learn to hand fly like us old pilots and you will be fine. Relying on automation works sometimes.

Hikoushi - another :ok: from me

hikoushi
 

Absolute nail on the head with that post.:ok:

"I am sure the MPL will improve things"

In this case not having an MPL didn't help, so maybe it will....

The most sensible post so far on this thread was the one about ther but for the grace of God etc...

What you can say is that the individual crew, all of flybe's other Q400 crews along with their training department and any other company's Q400 crews who read the aaib report will have learned from it. Anyone who hasn't flown a Q400 is just guessing.

Indeed, the man who never make a mistake never made anything, we all screw up once in a while which is why we have two people up front to keep an eye on eachother. The PNF should always be alert and ready to cry foul. Complacency is the great enemy.

If in doubt hit the power and go round, even if you only have an unexplained feeling that something is not right, you probably dont have time to figure out what is wrong, just get out of there.

I have never understood why so many pilots feel that a go-around is somehow shamefull or a sign of weakness.