Here's something to keep you at the edge of your seat
 

Report: Bulgarian Charter MD82 at Lourdes on Jul 16th 2018, go around without thrust change

Bulgarian Charter MD82 at Lourdes

Wow wow wow

They where lucky to be in Lourdes by all means 😱

Probably lucky they were not underslung engines or the actual go-around might have been very interesting.

Wow.....

Made me think.. In this modern era of tech and surveillance etc. Is it routine at Airports now to record AC movements? I.e CCTV of the runway from the tower??

Regardless of fatigue, tunnel vision, imperfect CRM or whatever...

If you see and feel that your aircraft is clearly not performing as expected isn't any airman first thought to check the thrust levelers ?

Safety Recommendations
 

Taking into account the causes of the serious incident and the deficiencies found in the investigation, the Commission recommends that the following measures should be taken to ensure the flight safety:

BG.SIA-2018/08/01: AO "Bulgarian Air Charter" must organize and carry out additional theoretical CRM training course, and the A/C crewmembers, who have caused the serious incident, must undergo a flight simulator check.

BG.SIA-2018/08/02: During the next flight simulator training session, all MD-82 pilots of AO "Bulgarian Air Charter" to include an exercise with similar conditions for flight performance as in the case of the serious incident.

Scary stuff indeed.
Even from day 1 when auto throttle is introduced for the first time on a B737-800 MCC/APS course, it can be highly addictive, similar I am told to ‘crack cocaine’....?
So from day 1 the trainees are taught to follow the thrust levers forward as TOGA button is pressed, and during any scheduled thrust changes.

From time to time they will forgot on the G/A, so A/T fail is smartly selected on the IOS panel and nature is allowed to take its course. They tend to remember in future......at least during the course.

Swiss cheese event again and the comments are valid. What I find surprising is the absence of any comment on the flying experience of the Captain! In so many threads the amassed hours total of the individual is touted as a mark of competence - maybe not?

May I please ask why you think this can be explained by the Swiss Cheese Model? (a serious question regarding the effectiveness of different types/styles/methods of incident investigation)

I would have thought that most incidences would be better explained by conducting a root cause analysis rather than a investigation into what barriers failed?

One of the limits of root cause analysis is that "you can't fix stupid". OK a little strong when applied to this event, but one must be willing to look at any future actions at the machine level to lessen the result.

I don't think this is a case for the Swiss Cheese Model, there's not too many holes in the cheese that have lined up here.
The root cause analysis works better in this case and looking at the recommendations from the Bulgarian AAIB that appears to be what the investigators have done.

True.
I was taught that there must be a single causation event in order to bring the barriers into effect.

Exactly, in this case it appears to be lack of or poor training / CRM.

Yet another classic example of automation dependency and blind addiction to flight director commands. Extract from the official report:

" After about 5 seconds and a 350m flight into the runway, the captain commanded “GO AROUND”, pressed the “TO/GA” button and started following the flight director arrows, further increasing the airplane's pitch, but not noticing that the thrust control unit (Autothrottle) was still OFF and did not put manually the throttle control in the required take-off position for a“Go Around”.

Maybe the crew were used to not hearing the engines, (which are a long way aft of the flight-deck) and therefore this audible cue was not available to them? In other words, it sounded normal, even though it can’t have felt normal?

It’s truly a miracle they survived 😁

I believe that you have firmly “hit the nail on the head“

The value of having your hand on the throttles even when the A/T's are engaged. The BASIC crosscheck that we learned in Flying 101 still applies - aimpoint, airspeed, power. Repeat, repeat, repeat, repeat....idle, flare, land.

Ok I can understand the mistake(s) but at some point they muss have felt it through their ass pants. This aircraft was clearly not getting the expected thrust - any pilot will check the thrust setting as a reflex.

I don't know what would be typical in an MD82 but I'd expect would feel the TOGA thrust with 3-5 s of commanding it. There is no missing it - I find it unbelievable that the remained spectators for about 20s...

This illustrates why the Airbus FBW designers fitted TOGA switches that can only be manually activated by pushing the thrust levers fully forward.

The problem with having TOGA switches on the thrust lever handles is that you can press for TOGA without pushing the levers forward, and believe TOGA will result. You should also push the levers forward, but as we have seen too many times; when things start going wrong, the human brain can shut down when it cannot understand what is going on, and things get missed. I suspect that having pressed the TOGA switches, the PF believed the engines would spool up and his brain capacity was full while fighting to understand the situation and control the aircraft, so he did not check the thrust.

I believe Airbus designed their thrust control system to avoid this problem. Also, by not having the levers back driven, Airbus pilots are required to look at the N1/EPR gauges to confirm thrust changes and not rely on the proxy of moving levers: So they keep in practise of looking at the gauges, which of course is good practice anyway.

Another point is that if the approach conditions are blustery with significant crosswind and turbulence, it is useful to take manual control much earlier than 470' agl. 7 miles gives one time to "get in the groove" of blustery weather conditions and get your responses up to speed before getting to short finals and the flare :ok: