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-   -   Final Report: April 2018 737 high speed aborted TO (https://www.pprune.org/rumours-news/638276-final-report-april-2018-737-high-speed-aborted.html)

vilas 27th Jan 2021 16:18

ManaAdaSystem

I didn't mix AIRBUS but somebody wrongly quoted Airbus FCTM I just posted the correct version. Airbus also doesn't recommend reject after V1.

vilas 27th Jan 2021 16:27

In the present case reject wasn't necessary but having decided to do it it should have been executed properly without wasting precious moments on any trouble shooting. In general if you cannot rotate even with proper procedure then reject is the only answer whatever the result.

Stuka Child 27th Jan 2021 17:30

I was going to shut up, but I just can't. This is addressed to no one in particular, but to some of the arguments which have been presented here.

Every procedure, whether designed by the manufacturer or your company, is based on the assumption that a conscious mind operates your brain, and that said mind is capable of understanding and reacting to situations correctly, and making optimal if not the best decisions to give everyone on board the best chances of making it in one piece. If that weren't the case, there would be no pilots.

This whole "go-minded" stuff was not caused by horrible takeoff overrun accidents that killed everyone on board. Yes, people have tragically died in overruns (mostly on landing) and it is not something to take lightly. However, you have 1000 times more chances of dying in a LOC accident while in the air. The actual origins of these procedures are the following: X, Y, Z aviation safety people examined a series of aborted takeoff above V1 incidents (many not resulting in overruns mind you!) and figured out that most of these were perfectly flyable aircraft, and that the takeoff was aborted for some insufficient reason that in the heat of the moment seemed critical to the crew. Conclusion: there is statistically very rarely a valid reason to reject the takeoff after V1, so it makes sense numbers-wise to "force" pilots to press ahead, because much more people risk to lose their lives if we continue to allow these frivolous rejected takeoffs than the 200 lives we're going to save when once in a blue moon there is actually a valid reason to attempt to stop. Or, more cynically, it could be about tyre costs. Realistically, it's probably a bit of both.

Let's take an example where the runway is too short to stop once you've passed V1 and the overrun is guaranteed - which again is not always the case. Now think about it. What offers your passengers the best chance of survival? Driving into the forest at the end of the runway while slowing down? Or nosebombing the same forest from the air because you took off with your wing on fire like a dumbass? And it doesn't even have to be something as dramatic as a fire chewing off bits of airfoil. Anything that would cause an aircraft to refuse to fly is a great reason to stop, no matter the speed. Same if you suspect possible imminent structural failure (wing on fire example). For the life of me, I can't figure out why you would try to power your way through that.

Obstacles at the end of the runway and to the sides are a concern, of course, but you should already be aware of these things before you even report for duty. It is your job to know the aerodrome and have plans in case something goes wrong. Where are the obstacles in case of an overrun? Where can I go? If I have a dual engine failure, where can I go? If I'm already in the air, where can I put her down to give us the best chances? If you're thinking about these things during a takeoff run, you are late. This is no time to discover the layout of the airport. The homework should have been ready from before.

Making the correct decision within seconds is what saves lives or elevates them from this earthly plane in a violent manner. And despite what you might think, there is no procedures and no checklist for decision-making. That burden lies squarely on your shoulders. Try to get used to it.

what next 27th Jan 2021 18:18


Originally Posted by Stuka Child (Post 10977466)
And despite what you might think, there is no procedures and no checklist for decision-making.

Excellent post, Stuka Child. This is the very reason why my alarm clock is set at 5:00 tomorrow morning because no one invented a device yet that could do that for me.

B2N2 28th Jan 2021 04:36

We are but mere mortals some just more then others.

Captain Sullenberger and Captain Haynes come to mind.

We will all be judged by our decisions.

pineteam 28th Jan 2021 04:58

The number of people who think it’s ok to reject take off above v1... What am I reading here?! Unless you lost a wing or something after V1 you go. Period.
Some guys survived miraculously car accidents without wearing a seat belt. Does that mean it’s the right thing to do? Certainly not cause it’s undeniable that wearing the seat belt is safer overall.

Originally Posted by ManaAdaSystem (Post 10977148)
You pass V1, start to rotate and nothing happens. What do you then?.

We did that in the sim. Toga and rotate using the trim wheel

Edit: Nice Post Stuka Child!:D

George Glass 28th Jan 2021 05:42

Some posters need to have a bit of a chat with their Check Captain about this issue at their next License Renewal sim. session.
Of course if ,in fact , they ever do one............

vilas 28th Jan 2021 09:05

We are discussing a takeoff that was rejected for a wrong reason and not even correctly executed. There are hardly any accidents that required split second decision. In takeoff incidents wrong decision is the major cause. So let's not go overboard. Most accidents are caused by incorrect handling of straightforward procedures without any time constraint. After V1 only at Vr one will know whether aircraft will get off with only option of trying other side or stabilizer. If it doesn't then you reject and accept the result. But for this one in million hours possibility you cannot throw the standard procedure of being go minded out of the window.

Landflap 28th Jan 2021 09:25

Pinetree & George, thank heavens. Thought I was on my own there ! Trust some of these posters are not pilots. I doubt that any professional, trained and practiced pilot would even contemplate stopping after V1.As I said before, keep the discussion in the classroom please. Out in the tough world, it is a no brainer. Boeing seem to agree. Airbus seem to agree. I got through 40 years of sim tests where if I continued after V1 but pleaded that I was "thinking outside of the box" I would have been granted a bit of re-education. Persisting in the dangerous delusion would have resulted in job termination. Quite rightfully so.

excrab 28th Jan 2021 10:46

vilas

I would agree with all of that, except for the first part of the first sentence. Boeing are quite clear in the QRH, that:

Above 80 knots and before V1, reject the takeoff for any of the following:
  • any fire or fire warning
  • engine failure - confirmed by two parameters
  • blocked runway
  • take-off configuration warning
  • control malfunction
  • predictive windshear warning
  • if the airplane is unsafe or unable to fly.
That’s a cut and paste from the 737-800 QRH at the airline I currently fly from. The decision to stop was for a correct reason, if it was taken before V1, but the problem was in the execution, and that shouldn’t have been an issue because there are four simple steps in the initial RTO which any B737 captain should have engraved in their muscle memory, should review in the before take-off emergency brief, and be mentally rehearsing throughout the take-off role.

However, looking at the report, it would seem that despite what was written in the tech log the decision to reject was almost certainly taken above V1, and the process was slowed down further by attempting to fault find. Those were both errors which shouldn’t have happened, but in defence of the crew involved I wonder how much is due to the way simulator training is conducted. I’ve been flying the 737 for fifteen years, so nowhere near as long as some of the posters here. I’ve flown it for five airlines, so I’ve done about 26 recurrent checks and five OCC’s, three of which were excellent and covered virtually the whole type rating course, one of which included the type rating so was even better (that was the first one, obviously), and one of which was two sim sessions then a proficiency check, so wasn’t quite as good. But in every OCC except the initial type rating, and in every training or checking event, at five different airlines, every RTO has been for a fire or engine failure, and every RTO has been conducted with either 125 or 75 metres visibility, and every RTO has been initiated by a failure or fire two or three knots below V1 and every EFATO has been initiated 2 or 3 knots above V1 because the instructor or examiner has set that on the touch screen on their IOS because they either want you to stop or they want you to go, and don’t want some grey area right in the middle, exactly at V1 where in a non EFIS aircraft the width of the ASI needle can lead to discussion.

Not once, in any of those events, has the RTO been performed when taking off from a wet runway, in the dark, knowing that if we get airborne then at four hundred feet the LNAV is going to command an immediate right turn and we are then going to climb on a 4 DME arc around the Kathmandu VOR with the flaps out until we get to about three thousand feet above the airfield, which is going to take forever if we lose an engine, and we are going to climb to about twelve thousand feet to get across the foothills of the Himalayas to our take off alternate which is a dreadful sh*thole in India, and knowing that if we had a major control malfunction or a fire that wouldn’t go out then if we can’t get to that sh*thole our only option is, if we’re lucky and have the approval is to fly fourteen miles from Kathmandu and then return flying a curving RNP/AR approach through a narrow valley, or even worse, without the approval, fly a steep VOR approach where once you get to 4 DME and you’re visual, in the dark, in your burning or barely controllable aeroplane you are going to increase the rate of descent to get down onto the three degree PAPI slope for the visual landing, and if in the stress of all that, which you have never practised even in your Cat C training you get it wrong and have to go around then you are going around towards high ground where the MSA reaches 28,000 feet within 25 miles of the airfield.

Having been to Kathmandu many times, despite knowing that we stop below V1 and at or above V1 we go, I’m not sure, what I would have done, without the value of hindsight and a thread on prune to learn from, If I’d been in the left hand seat of that aircraft and had got a configuration warning at or slightly above V1, except I hope I wouldn’t have tried to find out if it was real, in the same way as we don’t try to find out if a fire warning is real, or a wind shear warning is real, we just assume it is and react. I’m probably going to get flamed for this by the pundits, but after thirty five years of flying for a living I’ve learned that it’s easy to sit in the back of a simulator or in an armchair and pontificate, but we weren’t there, and we shouldn’t vilify someone for a mistake which at some point in our careers, before we knew everything from reading prune, we could have made ourselves.

George Glass 28th Jan 2021 11:02

Excrab , great post. ( Not being sarcastic! )
I have been to Kathmandu ( and Lukla ! )
I feel your pain.
But its your job.
That’s what you’re paid for.
When you do your flight planning , pre-flight briefing etc. and line up on the runway and press TOGA you should have a pretty comprehensive mental image of what you are going to do.
And be confident about it.
If you don’t you are in the wrong game.

sheppey 28th Jan 2021 11:22

The Malaysian AAIB report agreed with the captain’s declaration to reject the takeoff was well taken since the captain said it was unsafe to continue considering the airport surrounding terrain and bad weather.

That said, some would argue the sound of the configuration warning at V1 was so inconsequential that a continued takeoff was a safer option than a high speed abort beyond V1 on a wet runway.

The Boeing report at Appendix 5 of the AAIB investigation made the following observations of the conduct of the abort. The aircraft had already passed the V1 of 141 knots when the captain initiated the abort. The QAR indicated the abort commenced ten knots after V1 – namely 151 knots which put the aircraft further down the runway which was already wet. The maximum speed reached was 154 knots before reducing. That is 13 knots beyond V1

The captain immediately overrode the RTO feature by using manual braking as the auto brakes actuated. The RTO feature applied instant 3000 PSI but this was reduced to 800 PSI the instant the captain applied manual braking. It gradually increased to 3000 PSI over the next 20 seconds. . Full reverse was not used.

Boeing stated: “During RTO, reverse thrust, wheel brakes and autobrake were used; however not to their maximum capability. Reverse detent was used instead of maximum reverse which would have been expected on a wet runway and commanded brake pressure was reduced from the autobrake applied brake pressure of 3000 PSI to 800 PSI and gradually increased back to maximum brake pressure over 20 seconds.”

To an informed observer it would appear the decision by the captain to abort beyond V1 was more a panic move rather than a fully considered decision of all the circumstances. If, as the captain stated, a takeoff configuration warning occurred as the aircraft passed V1, there is little doubt that there would have been a WTF moment startle factor and a momentary delay before he elected to continue the takeoff or reject.

It is doubtful if the captain at the time of the takeoff configuration warning, would have found the time to consider terrain and weather before making an informed decision. More likely he made a snap decision to abort. But why stop?

The fact he dithered with the speed brake handle after V1 would indicate he was caught by surprise while still accelerating. Maybe he hoped it would stop the configuration warning which was distracting. When the noise didn't stop he then instinctively initiated an abort because he didn't know what else to do.

Regardless of his handling errors during the abort which would suggest a degree of technical incompetency, it would appear that to the casual observer there could be only one reason for his action to abort beyond V1.

The captain’s considered on the spot opinion that the aircraft may not fly in terms of possible handling difficulties and unknown gradient of climb.

Or: A startle or WTF factor so strong that standard operating procedure as espoused by the aircraft manufacturer in the flight manual was overridden by the captain's primeval desire to stay on the ground regardless of stopping performance considerations. In other words a panic driven abort which fortunately caused no casualties. What do readers think?

IcePack 28th Jan 2021 11:34

Reading this thread, I still get the impression, that a lot of pilots really do not understand the definition of V1 and how it relates to an abandon take off. I am sure someone on here can quote verbatim the definition. But for a start brakes should (already) be fully applied AT the V1 speed in the event of an abandon.

excrab 28th Jan 2021 13:26

My understanding from the FAA rules is that V1 is either the maximum speed at which the RTO manoeuvre can be initiated, or the minimum speed at which a take off can safely be continued in the event of an engine failure. As we are talking about the stop
case here this means that at V1 we should be (in the 737) 1. Disconnecting the auto-throttle 2. Retarding the thrust levers 3. Deploying the speed brakes and 4. Deploy Max reverse thrust. As we carry out the second action the auto brakes kick in. So max braking will not be already applied at V1.

Uplinker 28th Jan 2021 14:37

Yes, V1 is not the moment to start applying an RTO. When V1 is called by PM, it is already too late to begin a safe RTO - hence, many SOPs have the PIC removing their hands from the thrust levers as soon as V1 is called.

The actions of an RTO must already have been started by the time V1 is called - otherwise one must continue. What those actions are will vary between aircraft types.

Only in extremis should a stop be attempted after V1 - a catastrophic loss of control or airframe damage or separation etc.

PS, great post #50 exrab :ok:

safetypee 28th Jan 2021 16:17

The origins of 'go minded' are from work on the FAA Takeoff Training Safety Aid circa 1992-94 AC120-62. At a similar time the definition of V1 was harmonised world wide; the FAA had to 'add' time for recognition used elsewhere, and redefine with 'first action'.

Some US operators had difficulty with this, resorting to 'procedural' adjustment - calling V1 slowly, or starting 5 kts before the decision speed.
Within this, the hypothetical cases appeared without due consideration of requirement or risk; also the Unions promoted 'Except', more for legal cover than safety or practicality. The result was a legacy of indecision and inaccuracy imposed on the world via FAA and Boeing / Douglas.
In later years Airbus have provided balancing views in a range of safety publications (no 'except' in their drill?)

An ideal procedure is a simple If-Then.
There are a few time-critical events requiring 'automatic' pre-conscious action with little need for situation assessment: 'Pull Up', 'Wind-shear', 'Descend'.
Conversely RTO is one, if not the only time-critical situation which requires situation assessment before acting.
The situations for 'automatic' action are defined by technical systems (EGPWS, TCAS).
RTO situations are defined by 'people', individual perception and assessment, judgement of 'failure', in a time limited period, with inherent bias of human thought.

We construct RTO situations in our head at the particular moment; our interpretation of reality.
How we 'create' these situations is the dominant factor in modern RTOs. Yet increasingly our minds are cluttered with inappropriate knowledge, ill-informed hypothesis and wild supposition from others. The unbalanced fears from extreme situations or outcome, or risk, will resurface from memories biasing our thoughts in those rare and surprising situations where the clarity of If-Then is required.

Dispel hypothesis with fact, validate assumptions, check regulations, and rationally evaluate risk. These with a 'go mindset' will help judge and choose an appropriate action.

No choice is perfect, but it should at least be well considered based on prior understanding and knowledge; then doing what is perceived to be correct, at the time, for 'your' situation, no one can rationally judge otherwise - because they were not there.

Stuka Child 28th Jan 2021 16:29

pineteam

Thanks for the love :O

No one is saying it's ok to reject after/above V1, but it is an indisputable fact that in some rare cases this is exactly what one must do. I can name you off the top of my head accidents with heavy loss of life, or death of everyone onboard, where the correct action was to stop and take the overrun if needed, but the go-minded captain went...and came right back down in a big fireball.

Miraculous escapes from car accidents are not exactly the best comparison. Aborted takeoffs above V1 are a relatively common occurrence despite what is being suggested on these fora, and the VAST MAJORITY of them end with no major damage to the aircraft, let alone hull losses or fatalities.

If anyone would like to see some numbers to compare fatalities from RTOs above V1 vs loss of control immediately after takeoff, I would be more than happy to pull them up and compile them for your viewing pleasure.

PPRuNe is a funny place. Operate outside of procedures (or on the thin grey line) and keep everyone alive, you are pilloried. Do something really stupid and kill everyone, you become a martyr - "oh don't blame the pilots" and all that hoo-hah.

GlobalNav 28th Jan 2021 17:27


Originally Posted by B2N2 (Post 10977718)
We are but mere mortals some just more then others.

Captain Sullenberger and Captain Haynes come to mind.

We will all be judged by our decisions.

In the cases of these examples, the decisions were made long before, and habitually, before the famous incidents. Decisions which demonstrated their professionalism and preparing them as well as could be done for those brief and perhaps singular events that defined their long careers.

tdracer 29th Jan 2021 00:15

Stuka, I'd like to see that.
Years ago, Boeing did a study of exactly that (aborting above V1 vs. continuing) and concluded just the opposite. The percentage of aborts above V1 which resulted in "catastrophic" outcomes was quite high (catastrophic being hull loss and/or multiple fatalities), where as cases where the aircraft was "unflyable" were extremely rare.

George Glass 29th Jan 2021 01:40

Stuka

You’re making it up.
Spot the Flight Sim. driver.
td is correct.
Put up the numbers or shut up.
Oh , but thats right , they don’t exist.

Icarus2001 29th Jan 2021 02:44


If anyone would like to see some numbers to compare fatalities from RTOs above V1 vs loss of control immediately after takeoff, I would be more than happy to pull them up and compile them for your viewing pleasure.
I would love to see the numbers, with their source data.

Chris2303 29th Jan 2021 05:15

Incident: EAT Leipzig A306 at Brussels on Nov 26th 2020, rejected takeoff above V1 due to difficulties becoming airborne

Incident: EAT Leipzig A306 at Brussels on Nov 26th 2020, rejected takeoff above V1 due to difficulties becoming airborne

jmmoric 29th Jan 2021 08:43

https://havarikommissionen.dk/luftfa...2019/2019-234/

Think we can find a number of incidents where the decision to abort late in a departure was the correct choice.

Momoe 29th Jan 2021 10:32

Way beyond V1 and VR - airborne

vilas 29th Jan 2021 10:57

These are just exceptions that only prove the rule.
That you must not reject after V1 is not disputable at all. It's as bad as saying A few get the multimillion dollars lottery so every one should come out of school and put all that money in buying lotto tickets. Never know!

Beamr 29th Jan 2021 11:24

Some may find this an interesting read: https://code7700.com/pdfs/nlr_reject...f_after_v1.pdf

As a background: The complete sample encompassed 135 high speed rejected takeoff accidents and serious incidents. In 90% of these cases the aircraft could not be stopped on the runway. The statistical results are presented for the period 1980-1993 and 1994-2008 separately.

Based on the study while 100% of pilots believe that the RTO is the correct choice to be made on the occasion, in hindsight only ~32% of the RTO decisions were correct ones. However, ~44% are clearly bad decisions, leaving ~24% of the cases unclear.

Take what you will out of it.

olster 29th Jan 2021 12:54

Reluctantly I will join the fray. The incident in question was not at night time. The weather was fine (no thunderstorms). To reject a take off after V1 is wrong as per both main manufacturers guidance, backed up by industry and regulation. As already pointed out, rto beyond V1 in the simulator will end in repeat, retest or fail. Why? Statistically go minded has been proven the safer option as per Boeing FCOM / FCTM / QRH guidance material. But hey, what do they know compared to the armchair experts who have already proven that they are unaware of the industry definition of V1. It is not decision speed as previously understood from the 90s.

The report has been translated from another language and there are some ambiguous issues through translation. The accident report does not say that the decision was correct. National air accident reports are compelled not to apportion blame. It was the captain’s view post event. To reject post V1 and even then not conduct the rto properly is not role model performance even though apparently it is offensive to call it incompetent. Go figure.

I am only contributing in order to correct all the misleading rubbish that appears here. In the unlikely event of a current younger B737 pilot reading this and debating even in their own mind whether it is acceptable to reject post V1 because of an incident in an HS748 at Stansted 30 years ago.Dangerous and misleading. I have got 25 years of flying B737s and been a TRE for 27.Also flown out of KTM many times. Sorry for the willy waving but I just want to emphasise that the report describes an incorrect manoeuvre. I do not want to hang out the PIC to dry; we all make mistakes and we can learn from them. Cheers.

alf5071h 29th Jan 2021 15:15

olster, et al, your concerns reflect mechanistic modern industry, the expectation of unambiguous situations, decisions which can examined without bias, and only one 'right' outcome vice being 'wrong' in so many ways.
This is not the real world; operations are uncertain, and as much as we try to remove uncertainty with rules and procedures, the unachievable ideal remains embedded in our imagination.
^^^
Re the 748; context is everything. The good outcome - an innovative violation, providing opportunity to lean.
Alternatively a poor outcome, 'blame' - because the LP fuel cock was not turned off in the fire drill ('read the report'), opportunity to learn.
^^^
'Risk is the amount of uncertainty we have to manage'.
Intelligence:- the ability to manage uncertainty; to learn from experience.
… an ability to adapt to the environment. People who are intelligent can learn, reason, solve problems and make decisions that fit their real-life circumstances.
… is something that you can change through life. It is constantly updated by your interactions with your environment.

Real world problems:-
Are for high stakes, sometimes life-changing ones
Are emotionally arousing, to the point that emotions often cloud people’s better judgement
Are highly context-driven, requiring people to balance many conflicting interests
Lack a single “correct” answer
Lack any indication that there even is a problem; or else, the nature of the problem is unclear
Need a collective solution, often by people with different backgrounds and interests
Offer only vague paths to a solution, or seemingly no good paths at all
Unfold and need to be solved over long periods of time (but time is limited)
Make it hard to figure out what information is needed or where that information is to be found
Come riddled with numerous bits of false or misleading information, sometimes deliberately posed to make a valid solution more difficult
Solving such problems requires a mixture of creative, analytical, practical and wisdom-based skills – the foundation of the notion of adaptive intelligence.
Adaptive intelligence is relevant to solving complex problems in the real world. It consists of four main skill sets: creative thinking, analytical thinking, practical thinking and wisdom (the quality of having experience, knowledge, and good judgement).

An extract from New Scientist - Essential Guide to AI.

Humans must not be evaluated with mechanistic analysis after the event.
The real world is not If-Then; it is full of exceptions,
Except Pull Up, … !

MikeSnow 29th Jan 2021 15:20

I searched the ICAO database ( https://www.icao.int/safety/iStars/P...tatistics.aspx ) for accidents with fatalities related to takeoff in the last 13 years, as the database only contained accidents since 2008. This is what I found that may be somewhat relevant to this discussion:

Crash: Avient Aviation MD11 at Shanghai on Nov 28th 2009, overran runway on takeoff - 3 fatalities
Spoiler
 


Accident: Bek F100 at Almaty on Dec 27th 2019, lost height shortly after takeoff and impacted building after two tailstrikes - 13 casualties

Spoiler
 

Crash: NOAR L410 near Recife on Jul 13th 2011, lost height - 16 fatalities

Spoiler
 

Crash: Ababeel IL76 at Khartoum on June 30th 2008, hit ground immediately after takeoff - 4 fatalities

Spoiler
 

alf5071h 29th Jan 2021 15:38

Mike, the examples are not relevant because of either prior mistakes; i.e. as per 'spoiler'; mis-set thrust, no flap, icing check, which should have been identified before commencing takeoff, or because of system failure after take off.
These do not related to situation assessment and decision making at a critical point during takeoff.

excrab 29th Jan 2021 15:51

I apologise, Olster, but the first part of your post makes no sense to me. You say the incident wasn’t at night, but the report states that it happened at 1621z, or 2205 LT, so it most definitely was night, being about 3 1/2 hours after sunset. You also say the weather was fine, with no thunderstorms, but we can’t draw that information from the report. It states that both crew members were aware of the bad weather in Kathmandu, and the latest METAR given in the report was at 0820, eight hours before the incident occurred, so totally pointless as far as the report is concerned. Even if they had included a weather report at the time just because it’s fine at VNKT doesn’t necessarily meant it’s fine in the valley between GURAS and the KTM. So I don’t see how we can discount the fact that the PIC may have had bad weather in his mind when he decided to reject, just from that report.

You also mention the HS748 crash at Stansted. This has, as you say, no relevance to the accident at Kathmandu, as at Stansted they didn’t reject above V1, they got airborne and then landed straight ahead on the remaining runway. However I think it is very relevant to the subject of simulator training, emergency drills and decision making. Had they continued into the air and carried out the standard drills and requested vectors back to land at Stansted they would have been airborne probably for fifteen minutes, and had the fire not gone out maybe the wing would have failed structurally. Maybe it wouldn’t, no one will ever know, but what we do know is that as a result of the Captains decision that night everyone walked away from it, and the AAIB report stated that the decision was sensible in the circumstances. Personally I think that every pilot be they young or old, flying 737 or any other type should be aware of that accident, and think outside the box. It’s really easy to say that in the simulator rejecting after V1 will require a retest, so we should never do it. But when we are accelerating down the runway, passing 150 kts and above V1 and suddenly something happens that makes us think that the aircraft is unsafe or unable to fly should we never stop? In a 737 on a 2000 metre runway probably not. But on a 4000 metre runway when we’ve got 2500 metres of it still in front of us, why not ? Real life isn’t the simulator. In real life we can’t be certain of the outcome of a scenario because we know what failures we’ve programmed, what speed we’ve armed the engine failure at, whether the fire will extinguish on the first bottle, or the second, or not at all ?

olster 29th Jan 2021 16:26

I don’t really want to get involved in further debate on this. You are either in the industry and understand how performance works or you are not. It should appear obvious that you have to have a set of rules and understanding how go / no go decisions are made. The HS748 incident is not relevant in this context nor really any of the other examples. The general view here is that we have to have endless debate with a kind of free for all over the reject decision. Is that what we want or is it better that we have rules and regulations that determine how we perform in certain non normal situations? Statistically it has been proven beyond doubt that approaching V1 to be go minded. Both Boeing and Airbus promote this and indeed it is rubber stamped by regulation. Also both manufacturers in different ways reduce the reasons for reject in the high speed regime. Whether you like it or not rto twice at V1 plus on a recurrent check under any regulatory regime and you can hand your licence in on the way out. The rules are there for a purpose. They are not made up arbitrarily. What I don’t like is the intimation that we don’t have to follow or understand the technicalities of take off performance, what V1 actually means and we can find our inner Sully and use our self proclaimed superior skills and intellect for non normal scenarios. Dangerous stuff. I might add, the incorrectly performed rto in this instance, beyond V1 might not have had such a happily casualty free outcome at other airfields.

excrab, you are right on the time of day. There is a confusing mismatch between the metars and the take off time which I misinterpreted. The weather was relatively benign. and although nighttime my views on this incident remain unchanged. Finally, I have spent one dimensionally my career in the real world since the late 70s and understand real world dynamics. I have been @ V1 @ night @ KTM. I am empathetic to the crew and I am not here to castigate but we also have to be honest and realistic. Cheers.

FullWings 29th Jan 2021 16:50

I agree with the above posters that it is not as simple as it sounds. When was the last time you were given a sim exercise where you had to reject after V1 in order not to crash? So, strangely enough, don’t reject after V1 in the sim!

Back in the real world, having an unexpected situation develop around V1, we don’t know in the case under discussion exactly where, leaves you in the position where rote behaviour (V1 = GO) is now at odds with cognition (can we fly?). I’m not a behavioural scientist but I don’t think you have to be one to realise that there is an awful lot of human factors here, not least the way we process information and make decisions, especially with conflicting inputs. I’m going to be controversial and say that one of the major causal factors here is a configuration warning that doesn’t appear to be inhibited at high speed - what’s the point of having it sounding if the consensus is that you should continue anyway? All it provides is an opportunity for confusion. On later aircraft, config warnings are inhibited approaching V1.

Statistically, it’s better to continue pretty much all of the time, so that’s what we train and what we expect to do. However, there is the possibility that one of us reading this thread may be dealt something truly nasty at some point in their career, like a multiple birdstrike at speed that causes multiple engine problems. Then you have to make a decision rather quickly...


PEI_3721 29th Jan 2021 18:03

FullWings, you observe two important points.

First in simulation; either the situations are not sufficiently challenging, or that we behave differently in a simulator than we might in reality. Probably some of each.
Simulators are not reality; pilots in reality may not meet the imagined reality in SOPs.

Second, that the technology in more recent aircraft reflects what is now taught and accepted as good practice.
Investigations into incidents in older aircraft should consider these later standards. It would be impracticable to expect that older aircraft be modified to the latest standard, but at lest the errant config alert could be improved to work as designed.

hans brinker 29th Jan 2021 18:41

olster

Sorry, but I have to disagree. In the SIM you get the same canned exercise year after year. I have 20 years of flying, and have never seen a reason to abort a fter V1, especially in the SIM. But I have landed on a runway covered in geese at night, and I struck a few in the flare. Had it been during take off there is a good chance I would have lost both engines. Dual engine failure after V1 is never trained in the SIM, to enforce the habit of aborting, because it is correct 99.9% of the time. But it is not correct 100% of the time.

sheppey 29th Jan 2021 23:25


Dual engine failure after V1 is never trained in the SIM
I have often wonderd why not. I don't mean near the ground but at high altitude where double flameout in a thunderstorm has occurred. Garuda 737 for example. The drill in the QRH calls for a re-start and hopefully one engine always re-lights. Now your troubles are over - end of exercise and box ticked.

But what if you are unable to get both engines going? Boeing avoid that situation and leave it to the pilot to use good airmanship (or is that NTS 1,2,3 or 4?) On the other hand full marks to Airbus. At least their QRH or whatever it is called in that aircraft, leads you into a forced landing with all its additional hints.

I have yet to see a Boeing simulator demonstrate a dead stick landing. He wouldn't have a clue anyway. if a dead stick landing is allowed by a keen instructor it becomes a "fun" exercise like a barrel roll rather than a serious session. Thread drift apology


Stuka Child 30th Jan 2021 00:19


Originally Posted by tdracer (Post 10978425)
Stuka, I'd like to see that.
Years ago, Boeing did a study of exactly that (aborting above V1 vs. continuing) and concluded just the opposite. The percentage of aborts above V1 which resulted in "catastrophic" outcomes was quite high (catastrophic being hull loss and/or multiple fatalities), where as cases where the aircraft was "unflyable" were extremely rare.

Now I'm not 100% sure we are thinking of the same thing, but I believe you are misremembering. What the study showed was that a high percentage of high speed RTOs were unnecessary and/or unjustified, versus the smaller percentage of correct calls. Pretty sure there weren't that many catastrophic outcomes.

There are many post V1 aborts that happen regularly. Much too many to list here. Of these, a number of instances result in overruns. Again, very long to list and I don't currently have a precise number, so I'd rather not say. A small number of these overruns result in fatalities. This is where we can actually dive into some figures.

This is the list of fatal accidents resulting from a high speed RTO, starting in 1980 (this includes aborts after being airborne, and I’m including even stuff like trying to take off from a taxiway or engaged parking brakes, taking forever to accelerate, etc.):

- JULY 1982: Philippine Air Lines 480, HS-748 at Yolo, 1 fatality out of 30
- SEPTEMBER 1982: Spantax 995, DC-10 at Malaga, 50 fatalities out of 394
- JANUARY 1986: VASP 210, Boeing 737-200 at Sao Paulo, 1 fatality out of 72
- JUNE 1986: Aeroflot, Tu-34 at Penza, 1 heart attack fatality out of 59
- JUNE 1989: Interflug 102, Il-62 at Berlin, 21 fatalities out of 113
- SEPTEMBER 1989: USAir 5050, Boeing 737-400 at New York, 2 fatalities out of 63
- APRIl 1990: Lao Aviation, An-24 at Luang Namtha, 1 fatality on the ground
- JULY 1992: China General 7552, Yak-42 at Nanjing, 107 fatalities out of 126
- SEPTEMBER 1993: Chaillotine Air Service, Falcon 10 at Besançon, 2 fatalities out of 3
- DECEMBER 1995: Chilean Military, CASA C-212 at Rancagua, 1 fatality out of ?
- JUNE 1996: Garuda 865, DC-10 at Fukuoka, 3 fatalities out of 275
- AUGUST 1998: Cubana 389, Tu-154 at Quito, 70 fatalities out of 91 + 10 on the ground
- MAY 1999: Kenyan Air Force, DHC-5 at Mandera, 1 fatality out of ?
- NOVEMBER 2000: Malu Aviation, An-32 at Luabo, 2 fatalities out of 11
- APRIL 2002: SELVA, An-32 at Popayan, 3 fatalities out of 8
- NOVEMBER 2003: Congolese Air Force, An-26 at Boende, 20 fatalities out of 24 + 13 on the ground
- JANUARY 2007: RAE 7755, Fokker 100 at Pau, 1 fatality on the ground
- JULY 2011: Missinippi Airways, Cessna Grand Caravan at Pukatawagan, 1 fatality out of 9
- MAY 2014: Private, Gulfstream IV at Bedford-Hanscom Field, 7 fatalities out of 7

TOTAL count: 317


So let's contrast that with loss of control accidents. Here are some fatal accidents where the crew decided to force the takeoff in an unsafe aircraft (non-exhaustive list this time, just want to give you an idea of scale):
- JANUARY 1982: Air Florida 90, Boeing 737-200 at Washington, 74 fatalities out of 79 + 4 on the ground
- DECEMBER 1985: Arrow Air 1285, DC-8 at Gander, 256 fatalities out of 256
- AUGUST 1987: Northwest 255, MD-82 at Detroit, 154 fatalities out of 155 + 2 on the ground
- AUGUST 1999: LAPA 3142, Boeing 737-200 at Buenos Aires, 63 fatalities out of 100 + 2 on the ground
- JULY 2000: Air France 4590, Concorde at Paris, 109 fatalities out of 109 + 4 on the ground
- NOVEMBER 2000: ASA Pesada, An-24 at Luanda, 57 fatalities out of 57
- SEPTEMBER 2005: Mandala 091, Boeing 737-200 at Medan, 100 fatalities out of 117 + 49 on the ground
- AUGUST 2008: Spanair 5022, MD-82 at Madrid, 154 fatalities out of 172
- MAY 2018: Cubana 972, Boeing 737-200 at Havana. 112 fatalities out of 113
- DECEMBER 2019: Bek Air 2100, Fokker 100 at Almaty, 12 fatalities out of 101

The entire number of people killed by takeoff overruns over a period of 40 years is equivalent to 2-3 LOC accidents. None of these lives should have been lost, and each and every one matters.
But if an accident is inevitable, I hope you can see which one will give you the best chance of survival.

(*main source: You can find them all in the Aviation Safety database, no matter the size of the aircraft. You just have to know how to search. The ones I was unfamiliar with I validated by going through the reports, just to make sure that they fit the criteria)

Conclusion: Yes, everyone knows we should be go-minded at V1. But that does not mean go at any cost. I see some of you saying, "oh you should never be in that situation anyway, these accidents were all preventable if they had made the right calculations, set the stab trim correctly, set the flaps correctly, etc etc.". But that matters zero! If you somehow find yourself in that situation, whether it's a wonky weight & balance, or wrong flaps setting, or ice or fire or a satanic force holding you by the gear, if you judge loss of control or structural failure are imminent, or that you cannot clear whatever obstacle you will be flying towards, you take the goddamn overrun!

Icarus2001 30th Jan 2021 03:54


These do not related to situation assessment and decision making at a critical point during takeoff.
V1 is the decision.

It is simply impossible to "make a decision" about the flyablility of the aircraft after V1. That is why we have V1.

This crew were "lucky". Some crews are unlucky.

alf5071h 30th Jan 2021 09:52

Why do you bother ?
 
I bother because I am still learning.
You are either in the industry and understand how performance works or you are not.”
Re 'industry', a yes-no answer.
Re 'understanding', an opinion, after the event, without assurance that my opinion or that of others is correct, at that time, in that situation.
Re 'performance'; for aircraft a simple yes-no, a line on the page.
Re 'performance' relating to people; this defies explanation, too many variables, thought, context, situation, etc; thus the use of Behavioural Markers, ratings, not numbers.

Consider a jump-seat CRM check-ride for this incident. You rate the crew at the moment the aircraft stops, as a crew member; a judgement call either way - but you are going to walk away.
Consider the same scenario in a simulator; a decision for a pre-programmed event chosen by you, where the outcome is known (one way or another) and can be judged (rated) yes-no.
Consider now, penning words to Pprune, with incident report and FDR to hand; another rating.
If these ratings differ, why.
If they are the same, why; which is easier to explain … and why.
Why do I bother, because its another opportunity to ask why, hoping to improve understanding.
Learning from the misfortunes of others.

olster 30th Jan 2021 10:43

Cheers George. I don’t know what happened to your post. The only reason I engaged at all is because the misinformation and lack of basic understanding masquerading as expertise is very dangerous and misleading. There are obviously very few professional pilots here but nevertheless everyone has an ‘opinion’. It is not up to me who contributes to these threads but it was optimum when those who knew what they were talking about posted.

Assuming you are in Australia, hope you are easing out of lockdown safely.


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