PPRuNe Forums

PPRuNe Forums (https://www.pprune.org/)
-   Rumours & News (https://www.pprune.org/rumours-news-13/)
-   -   Smartwings B738 over Aegean Sea on Aug 22nd 2019 (https://www.pprune.org/rumours-news/624858-smartwings-b738-over-aegean-sea-aug-22nd-2019-a.html)

rog747 29th Oct 2019 12:14


Originally Posted by gearlever (Post 10605786)
Would be interesting to know how much fuel was left.......

I am sure I read somewhere it was 900kgs -- or am I bonkers LOL

sewushr 1st Nov 2019 19:41

In the case of Smartwings' Prague to Gatwick route, just a temporary hiatus; the flight resumed today

fox niner 28th Nov 2019 05:54

Criminal proceedings are underway according to avherald.
Incident: Smartwings B738 over Aegean Sea on Aug 22nd 2019, engine shut down in flight, aircraft continued to Prague

gunshy67 4th Dec 2019 06:50

Just a queryRe ETPS
 
I wonder if the aircraft had an ETOPS approval...90/180/240/ etc minute?

Or the operators engineering approval?

Just checking.

fox niner 4th Dec 2019 07:10

But even then you have to land at the nearest suitable airport. Etops does not change that basic rule.

wiggy 4th Dec 2019 07:13

fox niner

I just replied in a similar manner then deleted my post on the grounds that I realised belatedly that gunshy67 must have been posing a rhetorical question...

gunshy67: you were being rhetorical.........weren't you??

rog747 4th Dec 2019 14:18

you dont need ETOPS on MED IT charter flights - not even for the Canary Islands unless you are coming from the USA or Canada lol

FlightDetent 24th Jul 2020 04:49

Czech AAIB report is out.

DaveReidUK 24th Jul 2020 06:28

But in Czech only.

Porto Pete 24th Jul 2020 06:31

Only the Czech language version so far: LINK

DaveReidUK 24th Jul 2020 06:51

With help from Google Translate:


3.2
Cause

The cause of the serious incident was a faulty decision-making process of the pilot-in-command after the loss of the power unit, which was not in accordance with QRH and FCTM procedures. These procedures are binding.

Event string:

operation of the fuel pump to "dry" before critical flight, see DL No.107847,

operation of the fuel pump to "dry" without fuel as a lubricant during critical flight,

engine shutdown and consequent loss of the drive unit,

obvious ignoring and violation of OM air traffic procedures, relevant regulations, provisions and safety recommendations,

Defective determination of a suitable aerodrome for a safe landing with one power unit inoperative after a fuel pump failure

faulty implementation of fuel policy,

the commander of the aircraft did not follow the principles of CRM implementation in the implementation of the NNC QRH procedure and thus prevented the F/O from participating effectively in the decision-making process,

by failing to complete the relevant NNC QRH procedure in point 10 of the Plan to land at the nearest suitable airport, the PIC has avoided the obligation to make a safe landing at the nearest suitable airport specified in the manufacturer's QRH and FCTM procedure and applicable to commercial air transport,

it cannot be satisfactorily demonstrated, nor can it be reliably ruled out, that the decisions of the commander and at the same time the flight director of the company were influenced by the economic aspects of the situation, as described in point 2.11.

parkfell 24th Jul 2020 06:59

“Pony express” mentality. Somewhat ironic being call “Smartwings”.....🧐

This all stems from the top and cascades down through the management ranks to the troops.
A management pilot at the helm.....and / or one who was just obeying
(his unwritten) orders....

AV Herald (27/11/2019) states that the Czechia’s District Prosecution Office had opened criminal proceedings and police investigation into the occurrence for suspicion of committing a crime of endangering the public due to negligence.
Can anyone update this information.......?


fox niner 24th Jul 2020 06:59

Did he resign? Was he demoted? Or is he still a TRE?

GKOC41 24th Jul 2020 07:55

Incident: Smartwings B738 over Aegean Sea on Aug 22nd 2019, engine shut down in flight, aircraft continued to Prague

The Captain/DFO resigned but is still part of the Management team according to a comment on Avherald

Ray_Y 24th Jul 2020 10:48

More translated details on AVH. I summarize in own words

Discussion between CPT and ATC delayed descend clearance after engine out
First Officer as PF increasingly worried about delayed descend, prepared for offset emergency descend due to decreasing airspeed.
Enourmous Command Gradient, CPT not cooperating with F/O on his worries
Investigation named 3 airports suitable for landing after unsuccessful restarts of engine
Lots of chips and fragments found in some Fuel System Components. also in fuel pump which also showed overheat traces from dry ops
CPT was FI, Flight Examiner and Flight Director in company. Approved OM, QRH, FCTM, FCOM documents, which he didnt follow on this incident flight.
And more details regarding eng perf on takeoff, fuel tankering vs. minimum fuel at alternate, and too high Engine out altitude

From interview with CPT:
CPT didn't tell ATC about Engine problem when requesting descend to FL240. He used a phrase like maintenance issue. He didn't feel like PAN PAN or more details
for ATC was of help.
They had to use MCT in order to maintain speed and level

alf5071h 24th Jul 2020 12:53

We should not judge less we be judged.
 
Reading the translated extract @ #151 without considering wider aspects, we might mistakenly conclude human error, which moves to blame and train, dismissal, …
Not wise.

parkfell, there is no evidence to support rash conclusions about 'mentality' or management, nor without explanation how we might learn from 'CRM'.

A philosophical view of 'cause' argues that because of inherent human variability and our inability to avoid hindsight bias, it is impossible to understand the actual human reasoning in past situations; humans cannot be a 'cause', only a contribution; both good and not so.
We learn from trying to understand that contribution, differences from the norm, both our and others expectations; there is little to be learnt from absolute conclusions - extreme positions without reviewing the supporting evidence. Hopefully the report will be translated in full.

In particular we need an understand why the decision making process was faulty; - because the academic view and HF teaching considers that both good and poor decisions stem from the same process.
Similarly for faulty implementation; a choice of action but how was this justified - a balance of probabilities assessed at the time in that situation, with recalled knowledge and influence of teaching, training, and experience.

Which specific principles of CRM were not applied, what are they, and how might they have been applied in a situation which we only see with hindsight.
A glib comparison with other accidents could conclude that CRM as a concept is flawed, because of the association of many accident outcomes with the often reported 'failed' CRM; but associations are not causation.

Opposed to seeking true cause (our view of it) there will be greater safety value by starting from a position that we don't know, and then consider influencing factors by which we can learn from this incident.

andrasz 24th Jul 2020 18:22


Originally Posted by alf5071h (Post 10845166)
there is no evidence to support rash conclusions about 'mentality' or management

I beg to differ...

For those of us familiar with this part of the world and in particular having some insight on this outfit that operated under a number of brands for the past 15 years, there was nothing surprising about the incident in question. Their operating philosophy was (and is) simply not to break the 11th commandment (Thou shalt not be found out...), while bending the rules and ever expanding the envelope of what they could get away with. Were there not the whistleblower at BUD ATC, there is a pretty good chance we would never have found out about this incident. There are very few EU registered airlines which are firmly on my personal no-fly list, they certainly are, for good reason.

The Old Swedish 24th Jul 2020 19:14

Google Translate:

4. Safety recommendations

1. ÚZPLN (pendant to NTSB) recommends Smartwings, a.s. based on the execution of the flight and the persistent conviction of the PIC that his final decision-making process was carried out correctly, perform a psychological examination at the PIC at the ÚLZ (Aeromedical Centre).

MATELO 3rd Aug 2020 10:14



Uplinker 3rd Aug 2020 11:57

alf5071h makes some interesting points. I don't know the full story and reasons behind the Smartwings flight but once in the SIM, I was PF when we had an engine failure in the cruise whilst somewhere over the Greek islands. I elected - and my Cap agreed - to fly to Athens rather than land on one of said islands.

My reasoning was that a) We were in an A330. b) We were losing altitude,(drift down), and had to make a decision since we did not have a lot of spare fuel. c) The weather was only good enough at Athens and at the runway on the island almost directly beneath us, I forget which one it was. d) We did not know anything about the airfield below us and we were in an A330, so e) I wanted a known long runway in case we found later that we had landing distance issues owing to reduced stopping ability. f) If we had had to go-around, we would have then been low on fuel, so would have had to commit to the single island runway. g) Athens was well within the descent profile, so we were not taking the aircraft beyond where it could safely go, it would have taken the same flying time to descend to the island runway as it did to descend to Athens, but Athens was not geographically the nearest airfield.

The TRE criticised my decision to go to Athens in the de-brief, and no doubt he was right, but I think my reasons were also valid, I thought that had I attempted to land an A330 on one of the shorter Greek island strips I might have embarrassed myself.


All times are GMT. The time now is 11:55.


Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.