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-   -   Turkish airliner crashes at Schiphol (https://www.pprune.org/rumours-news/363645-turkish-airliner-crashes-schiphol.html)

MU3001A 11th March 2009 04:32

Semaphore Sam - yes I would judge your comment to be pre-mature, premature too.

Tee Emm - Point taken. I meant of course the likelihood that if they were a little fast then the PL's were probably already at idle when RA#1 malfunctioned to command RETARD and that the crew fully expected the A/T would restore thrust at the appropriate time but failed to monitor. The idea of installing some form of stabilised approach criteria monitor alarm or warning would be to pick that up and alert the crew. I know in my case the guilt of knowing I am often a little faster than stabilized criteria might allow, has me keep a good grip on the PL's while eyeballing the airspeed intently, willing it to decrease so that I can restore thrust to its proper value. But then I don't have the luxury of A/T to do that for me which tends to concentrate the mind.

Wizofoz - I too am leary of adding yet more automation and I agree with all your points about SOP's and training and the culture of flying with automatics. But the plain fact is that adherence to stabilized approach criteria would have saved the day in this instance, but they are not being enforced precisely because application is left to the pilots discretion. Perhaps the flying public deserve a better standard of compliance with stabilized approach criteria than we have been able to effect to date and if such a warning system were devised I tend to believe that pilots would fear its intrusion rather than rely on it in the same way that controllers are wary of the snitch patch. It's gonna mess up the arrival rates at the busier airports but them's the breaks.

bobcat4 11th March 2009 06:03

GlueBall:


This warning does not apply to decaying airspeed or ground speed
I know. I was just answering Rainboes comment "Controllers do not fly or tell the pilot how to fly". Well, they does... Sometimes... When a MSAW alerts goes off. Wouldn't surprise me if MSSW (for speed) appears. Of course a lot more sophisticated then MSAW because minimum speed is not an absolute number.

The next plan I will fly has Vs = 35 knots. (!!) Yes, thirty five.

Wizofoz 11th March 2009 06:05


In which way did the TCAS contribute to this accident? As I understood it they would have been fine if the Tupolev had followed the RA.
True.

But EQUALLY true that if NEITHER had had TCAS and BOTH had followed ATC instructions, it would also have been avoided.

It's a prime example of how simply introducing a new magic box does nothing to improve saftey, and can be detrimental if it is not universally used correctly.

This accident is a case in point. Would it have happened if the AC hadn't HAD an autothrottle?

MU, agree entirely about stabilised approach criteria, but a rock solid culture of SOP adherence, total non-sanction (indeed, make it non-reportable) for a go-around due not being stable, and arse-kicking-to-follow if you press on works just as well as a new GPWS warning. People are capable of ignoring those too!

airbusa330 11th March 2009 06:20

Faulty altimeter, thust levers commanded to RETARD and subsequent stall seems to be the consensus.

Following the RETARD mode the A/T reverts to ARM unless disengaged by man or machine. Input from the air/ground sensor would cause the A/T to disengage 2 secs after touchdown, otherwise with the automatics engaged the A/T reverts to ARM, and with the speed still decaying the AFS pitches the nose down if the thrust levers are not moved.

Should you initiate a go-around by pressing TO/GA, the automatics disengage unless in a dual channel mode(not the case). Was there a mode confusion if a G/A was initiated?

So we need to know if the A/T was engaged at all in the first place.

There was an incident couple of years ago where a crew tried to circle of an ILS with the automatics in,the APP mode was exited by disengaging the automatics, however being too busy ''in and out'' the crew forgot to re-engage the A/T and subsequently reached the middle of yellow band but luckily recovered just in time.

There was a case also involving a 74 operation where the PM becomes PF at minima, who then as as he took over initiated a go-around without advancing the thrust levers. Speed decayed but was spotted in time.

Human has to know,monitor,respect and care for machine. Otherwise its a ''Garbage in garbage out'' outcome no matter how automated the automatics get.

airbusa330 11th March 2009 10:08

''Lawyers of the passengers(and relatives of victims) now consulting Lawfirm Speiser, Krause Madole & Lear in New York for further legal action''

Lawyers know exactly what and why it happened. Maybe it was them that advised Boeing on what not include in the operations manuals in the first place. Why don't they tell us then?

Lets wait for the transcript/investigation/conclusion. And at least the truth will be known. One positive out of a really sad event. Without sounding and touching a raw nerve, had it happened at home we would have never known as to the true cause. Neither did Lawyers for Aeroflot Flt 539 find anything wrong with children occupying a control seat.

Lawyers are only worried about their cut out of all this, like vultures on a carcass.

HarryMann 11th March 2009 10:12


Originally Posted by PJ2
But when we beat the aircraft, we beat ourselves; - the metal doesn't care and will do it again just as soon as it can.

So true, it certainly will under the same circumstances, even if admonished a thousand times... (visions of Basil Fawlty, Austin 1100 and a large branch come to mind :ugh:)

=====

FOQA ? Do Turkish operate such a scheme... sure it would have been mentioned * This would be one way of picking up continual approach busts, poor monitoring as well as that RA persistent failure.

If not, should ? now be thinking along the lines of enforcing such schemes in at least all European airlines above a certain size?

if there are 'cultural problem' airlines, would it not help get around that, the challenge coming from management or more dispassionate QA analysts with a stronger mandate (OK, I'll get shot for suggesting FO, SO hasn't the 'strongest mandate', so bullet proof vest on, but YUKWIM)

*YES, I've read every post, at some point

EXCIN 11th March 2009 10:19

Everybody is talking about the faulty radio altimeter as it is the main reason for the crash. :ooh:

The main reason are the 3 pilots in the cockpit. They didn't check their basic flying instruments and didn't fly the aircraft. How is it possible that a "well" trained capt and 2 FO's didn't see that that the thrustlevers were at iddle for more than 100sec :eek::eek: and that the speed was dropped to 40 kts below it's target ???? During the approach, you are supposed to concentrate on the instruments and on flying the aircraft (even if it is doing an autoland)
The reason for me : very bad CRM and very poor flying qualities.
I did some flying in Turkey and I was not at all impressed by their qualities. Most pilots are ex-Military and they are still using their grades. This is Major X, this is Col Y. In the cockpit, most Captains think they are God and don't accept any input from the FO. A Captain was (without joking) calling a FO, the "Flap Operator". This is cultural and it's very difficult to change this.
The same happens at many other Middle-East companies. CRM, CRM, CRM !!!

HarryMann 11th March 2009 10:27


Originally Posted by EXCIM
How is it possible that a "well" trained capt and 2 FO's didn't see that that the thrustlevers were at idle for more than 100sec

Obviously, because for 70 or more of those seconds they quite expected them to be there (though should have known the A/T 'state' of course)


CRM, CRM, CRM...
Mmmm, but to get there, as argued above, FOQA might need enforcing first across all large airlines operating into European airports

ant1 11th March 2009 10:31

Tee Em, that's what I think, too regarding the unstable approach issue.

I think we can easily agree that under the current state of the art in commercial aviation, HAL (AKA George) initiating a go around on it's own is not desirable.

The RA comparator issue would be more in the Boeing's (KISS) philosophy.


and with the speed still decaying the AFS pitches the nose down if the thrust levers are not moved
Again, not on GS, it's more like the A/T if ARMED will move forward due to alpha floor.

PPRuNe Pop 11th March 2009 11:10

Moderators are busy removing the untold rubbish and the crass stupidity that pervades this thread. It is better to THINK VERY CAREFULLY about what you write before pressing the submit button.

It really is getting tiresome - we are beginning to hear the echoes of ear splitting repetition!

Edit: Actually, it is hardly likely that anyone could add anything further to this thread that has NOT been said and repeated many times already - the CVR chat would help a lot though.

Oh! And while you might think you can use PPRuNe for a post chat - please don't - join MSN or such and don't waste our time.

PJ2 11th March 2009 17:03

HarryMann;

It was Basil Fawlty with a small shrubbery in hand swiftly beating his little car that I had in mind... and the thread itself deserves nothing less.

FOQA ? Do Turkish operate such a scheme... sure it would have been mentioned * This would be one way of picking up continual approach busts, poor monitoring as well as that RA persistent failure.

If not, should ? now be thinking along the lines of enforcing such schemes in at least all European airlines above a certain size?

if there are 'cultural problem' airlines, would it not help get around that, the challenge coming from management or more dispassionate QA analysts with a stronger mandate (OK, I'll get shot for suggesting FO, SO hasn't the 'strongest mandate', so bullet proof vest on, but YUKWIM)
Yes, I know precisely what you mean and have written about here dozens of times - Flight Operations is not concerned with flight safety. It is concerned with making money. While there are tiny pockets of resistance among enlightened airlines and their managements, the flight safety department is generally found far away from the main buildings, "down the hall, to the right...etc", an untidy, under-resourced backwater, a "senate-seat" for formerly ambitious men (strangely, no women), who were unfortunate enough to pxss in the cornflakes of someone above them on the way up or they had the temerity and courage to speak the truth at corporate safety meetings and challenge others' performance and statistics as reported by safety programs doing the job of providing data.

The descent, since the sixties, of the curve showing the fatal accident rate, now at an all-time low, is about to start climbing again. The Turkish accident is merely the latest canary in the mine. Too many who lead in government and corporate offices are comfortably numb or paralyzed by present economic difficulties. SMS means someone in middle management must stick his/her head above the trench and call an operation because of a crew's "difficulties with the MEL...etc, etc" and that will be the end of that person's career advancement. You can't put someone who is responsible for the bottom line, in charge of safety processes and decisions.

FOQA at Turkish? At a number of safety conferences I have met and discussed FOQA programs with both western and eastern European airline safety representatives. While intentions of many are earnest, FOQA struggles to survive because of bean-counter ignorance and short-term thinking/planning. I spoke with no one from Turkey but given the public statements in Hurriyet ostensibly expressing denial of what really happened to their aircraft I would not be the least surprised if no FOQA Program existed at THY but I don't know. I'm sure someone will correct me if THY has a FOQA Program, (in which case I have some questions for them).

The corporate ignorance (and increasingly, government ignorance as governments get out of the safety business and hand it over to private corporations), of how the industry has achieved the excellent safety record it enjoys today, is increasing, partly due to lost history/experience, but mainly due to the new politics of safety. Such collective ignorance is tacitly granting permission to airline managements to set aside flight data programs which inconveniently show that not everything is well. This isn't just an opinion or reading about others' experience in trying to breath life into data programs.


One last thing...if we need a bullet-proof vest for raising notions such as the focus and first priority of FO, then my point is made. In my experience this is half the reason why SMS, an excellent concept, will fail in reality; no leadership, reduced to nil regulatory oversight - the FAA/Southwest/American/United events are cases in point.

These days, robust safety programs and processes take too much of the bottom line. Perhaps airline managements have set aside "corporate ethics", (an oxymoron if there ever was one), and are under the illusion that it is cheaper to buy the insurance? Regardless, for those who understand aviation and the fundamentals that keep it safe, the dynamics are clear. Fatal loss of control accidents are matching CFIT accidents - we can see it in the data. The non-fliers who don't or can't listen will end up kicking tin and settling multi-billion-dollar lawsuits for their shareholders. The story rarely varies.

HarryMann 11th March 2009 21:19


Yes, I know precisely what you mean and have written about here dozens of times - Flight Operations is not concerned with flight safety. It is concerned with making money.
Although I was at Heathrow for a while in the aftermath of the BEA Trident Staines crash, I am not able to say for certain whether it was that accident that precipitated the adoption of, or became the precursor of, BA's FOQA programme... but it definitely had a very profound effect on the perception of (lack of good) CRM at the time.

The comparison of BEA Staines with THY AMS should be '..there but for the Grace of God go I'
It makes one wonder if a sufficiently strong suggestion that all souls could have easily been lost here might trigger a few synapses into making some links with absent FOQA programmes and meaningful CRM adoption... and the cost of a repetition.

N.B. The similarities in fact go further, with HSA being asked to detent the Trident's l.e.device/flap levers whilst Boeing may well be asked to modify the RA fit one way or another... bu there was no doubt the Staines accident was all about not flying the aircraft properly

Flyinheavy 11th March 2009 21:34

@study
........fly a raw data approach out of 20'000 ft from time to time.

Are you realy sure about that? I see no big challange in flying from 20K to the FAF with zero power. If it means intermittendly level offs, means lots of traffic I would consider this rather irresponsible. Besides you put a lot of stress on to your fellow pilot with no real benefits to gain.

In my last company we had 4 Sims every year, so if one wanted to sharpen ones handling skills, there we had plenty of opportunities.

Although I would agree in flying manual approaches given the right parameters (airport, weather, traffic etc) to do so.

mona lot 11th March 2009 21:39

As a current NG driver, I am astonished how so many "experts" have already managed to solve this mystery with so little information.

Until more official information is released no one can say what was going on in that flight deck, and attempting to do so is just disrespectful.

There is a lot more to this.

protectthehornet 11th March 2009 22:30

flyin heavy

if it is too much workload for the NFP so the FP can hand fly from the flight levels to a landing, then perhaps the NFP should put down his newspaper and wake up.

I am really ashamed at some of the things I am reading here. Imagine, hand flying a plane when you could press a button instead. That's like actually having a romantic encounter with a beautiful female flight attendant and letting something electrically powered do YOUR JOB>

shaking my head...where have all the pilots gone?

MU3001A 11th March 2009 23:13


In my last company we had 4 Sims every year, so if one wanted to sharpen ones handling skills, there we had plenty of opportunities.
OMG!

Could it be things are already worse than I thought?

PJ2 12th March 2009 06:20

pth;

shaking my head...where have all the pilots gone?
The answer is blowin' in the wind, pth.

For the practically-minded, it can also be found in the history of this industry from about 1978 or so...does the date sound familiar?

latetonite 12th March 2009 08:36

In a time were inexperienced pilots start instructing others how to fly airplanes, then buy type ratings and go sell their arts to the commercial aviation industry, the "swiss cheese holes" line up very quickly.
In this particular accident, the radio altimeter was a contributing factor, but the cause of the crash was what??
However, let us wait for the investigation results before we condemn.

dannyjet 12th March 2009 08:44


Originally Posted by airbusa330
Faulty altimeter, thust levers commanded to RETARD and subsequent stall seems to be the consensus.

I just learned with this accident how the RA commands the Retard mode in this aircraft and I find it quite umcomfortable.

I agree with wizofoz. Automatic systems are not entirely reliable. And being myself a pilot who hasn't flown the big buses yet, it creeps the hell out of me and makes me feel umcomfortable how dependent is one system of another.

At the end, connecting this thing with that, and that other one with this other one, opens the window of possibilities where if one fails, the other fails. It gets to a point where it doesn't matter if an indicator instrument is a primary instrument or a secondary instrument, or if it is needed to be scanned or not. Because in the end, the failure of any of these sub-systems can create any kind of trouble.

And yes, we hop into a new plane and we are thrilled by knowing how it can activate retard mode by RA indication. Ok that is cool, but what if the RA fails? What is the backup for this system if it fails and what is the backup for the other systems if this same system fails?

This crash could have also been prevented if the crew were in control of the airspeed. I mean, read that last sentence again and realize how pilots are not in control or are aware of the airspeed their aircraft is flying at.

Is there a concept called "Technology-Induced Pilot Error"? Because it seems to happen a lot.

Cheers,

MaxBlow 12th March 2009 08:57


The corporate ignorance (and increasingly, government ignorance as governments get out of the safety business and hand it over to private corporations), of how the industry has achieved the excellent safety record it enjoys today, is increasing, partly due to lost history/experience, but mainly due to the new politics of safety. Such collective ignorance is tacitly granting permission to airline managements to set aside flight data programs which inconveniently show that not everything is well. This isn't just an opinion or reading about others' experience in trying to breath life into data programs.


Excellent post PJ2, thanks.:D

This trend is indeed very scarry. Management forcing crews to take short cuts to improve profits. Flight Safety Managers have a position but no power whatsoever. Some Managers these days are not even pilots anymore.

They'll only learn when it's to late.

seckin 12th March 2009 09:57

CVR according to a Turkish Newspaper
 
Some Turkish Newspaper states that they have reliable information which is,
aprentice was in control on right seat, FO in the jumper, FO is the one who recognizes the situation and starts shouting throtle-throtle but as we all now it was to late.

Turkish Version (not the CVR, only the article)
"Gaz Hocam gaz" - GÜNDEM - HABERTÜRK - Türkiye'nin En Büyük Ýnternet Gazetesi

Aker 12th March 2009 10:29

Turkish Hurriyet newspaper today
 
headlined that investigation concluded that there are 3 reasons for the crash 1-) ATC forced the A/C quick landing pattern
2-) pilots paniced from the 1st reason
3-) Altimeter
I wrote this post with a details how funny reasoning and newsmaking without reliable evidence and moderator erased it i think some moderators here also manipulated .......

sami aker

No Sami it wasn't your 'funny reasoning.' The English could not be easily understood - that's all. Rob

Nigd3 12th March 2009 11:24

Daniel

In response to your question of "And yes, we hop into a new plane and we are thrilled by knowing how it can activate retard mode by RA indication. Ok that is cool, but what if the RA fails? What is the backup for this system if it fails and what is the backup for the other systems if this same system fails".

There are also two pilots to fit into the "system". Surely they are the primary means of controlling the aircraft, whether by monitoring the automation to ensure it is working correctly, or flying the aircraft manually.
Do you want backup systems to your backup systems, that aren't actually backup systems but aids to the pilot?

Maximum 12th March 2009 14:24

I'll attempt to add to what's been said and not just repeat.

It's hard not to jump to certain conclusions about this accident as this thread plainly shows. Before the investigators do their work, we're in the dark.

But to expand on what's been said and maybe give a focus to all the conjecture, I don't know if anyone's looked at the work of Dr. Charles Billings, former Chief Scientist at the NASA/Ames Research Centre. He put forward the idea of human-centered automation. To summarise, the basic premise is that the pilot/pilots are responsible for the safety of the flight. The axiom that flows from this is that the pilots must remain in command/control of their flights.

However, and this is the interesting bit I feel, in order to achieve the above, the pilots must be actively involved, the operators must be adequately informed and the automated systems must be predictable (my italics).

Leading on from this, it's interesting to note that the FAA have summarised two aircraft companies as having the following design philosophies near the top in a list of priorities:

Company 1: both crewmembers are ultimately responsible for the safe conduct of the flight.

Company 2: automation must not lead the aircraft out of the safe flight envelope and it should maintain the aircraft within the normal flight envelope. (source: Orlady and Barnes).

I'll let you decide which company is which.

It's easy for us to gloss over no.1 as stating the obvious, but it's crucial that pilots are aware of this philosophy so that they understand how they must approach and use the automatics.

(Similar to that page of explanation at the start of the QRH, easy to skim over, but again crucial to comprehension of what's expected of us when dealing with a non-normal).

I feel we will hear more of this in the weeks to come.

Flap 5 12th March 2009 15:29

It all comes down to: Aviate, Navigate, Communicate.

Even with an altimeter failure - in clear conditions this aircraft was 'aviated' into the ground.

aviator17 12th March 2009 17:33

Capt. ARISAN
 
As I mentioned before Cpt. ARISAN was a great person (yes he was an ex-military) every first officer in the company wanted to fly with him, we are really sad very sad...Just know that fact...Thank you...

Hiflyer1757 12th March 2009 19:40

No hard data yet
 
Unless I have lost my ability to search there has been no transcript, public playback, or even one direct quote from the CVR. Further, Boeing's memo on the FDR data fairly soon after the incident is pretty much the sum total from that box aside from some 'interpretations' during the Dutch presser. Meanwhile some of the more vociferous pilots here have been hanging the crew for various reasons but mostly for possibly violating the pilot code of 'be smarter than the machine or it will replace you'. On the other side some software types are pointing to this incident and saying 'see we need to make the software smarter to keep the pilots from making mistakes'.
Getting close to the definition of Catch-22 it seem to me.

Yes...that is generalizing but it seems to be the undercurrent for some of the last 30-40 pages in here. I agree wholeheartedly with those who have posted in here that we need to wait for all the data...a statement echoed repeatedly by the ATP licensed pilots that fly similar and larger aircraft that I interact with daily.

captjns 12th March 2009 21:13

The CVR will be translated into straight english, and possibly straight dutch. This will ensure the most accurate information to the investigators.

idle bystander 12th March 2009 23:25


Meanwhile some of the more vociferous pilots here have been hanging the crew for various reasons but mostly for possibly violating the pilot code of 'be smarter than the machine or it will replace you'. On the other side some software types are pointing to this incident and saying 'see we need to make the software smarter to keep the pilots from making mistakes'.
To be fair to the non-pilot types (not only software engineers, there are some system engineers) I think that what makes them, and certainly me, pretty cross is that a non-essential bit of kit (the RA), in fulfilling a non-essential function (retard in the flare) is allowed to announce its failure by two irrelevant, and confusing side-effects: first by telling the crew that the gear is still up, which they understandably ignored, being at 2,000ft, and secondly, and TWICE, retarding the power levers to Flight idle in the middle of an approach.

Any machine that will do that reduces me to a jelly. The system designer who allowed a side effect like that should be ashamed of himself.

And yes, of course the crew should have noticed what was going on, but I think we all know that something else was happening on that flight deck. If the CVR doesn't reveal it, perhaps the autopsies will.

dannyjet 13th March 2009 00:03


Originally Posted by idle_bystander
To be fair to the non-pilot types (not only software engineers, there are some system engineers) I think that what makes them, and certainly me, pretty cross is that a non-essential bit of kit (the RA), in fulfilling a non-essential function (retard in the flare) is allowed to announce its failure by two irrelevant, and confusing side-effects: first by telling the crew that the gear is still up, which they understandably ignored, being at 2,000ft, and secondly, and TWICE, retarding the power levers to Flight idle in the middle of an approach.

Any machine that will do that reduces me to a jelly. The system designer who allowed a side effect like that should be ashamed of himself.

That is exactly what I said on my previous post. I totally agree with you.

You presented it in a very well manner.

protectthehornet 13th March 2009 00:12

automation
 
the only reason I can think automation is installed is to make sure mediocre pilots can handle an airliner.

Lindbergh made it across the atlantic without an autopilot and he was awake a huge amount of time.

Yes, there were times things came a bit too close for comfort, but he made it.

So, instead of making sure pilots can fly the heck out of a plane, even ''expediting'' things with ATC, we have computers that can't do it and pilots who depend on the computers.

Damn shame. How many of you fine flyers out there know what a ''crowbar'' approach is? How many times have I intercepted a glideslope from above? There are thousands of you out there who know how to do it and make it work...even being spooled up in time to make sure you can get out of trouble.

alf5071h 13th March 2009 00:59

There have been several meaningless statements about poor CRM or lack of airmanship, or that crew should have ‘just flown the aircraft’; none provided explanatory detail, any reasoning, or offered a practical solution.
What part of CRM failed, how, why – if we knew, then solutions could be found? Similarly, for airmanship or flying ability, what critical aspects would have saved this crew?

One view of safety is that humans generate safety. Thus establishing what other crews have done in similar circumstances may help with an understanding of this accident and provide points of learning.
It is reported that at least one crew knew of the RA abnormality. Additionally, it’s hard to imaging that in the long history of the 737 that other crews have not encountered this fault – so how did they manage.

How did the crews detect the RA fault;- by viewing the display, an unusual alert (gear), or AT mode change?
Even discounting seeing the display, the alert and AT mode should still have occurred providing a range of cues.
An EGPWS gear alert is given when RA <500ft, which suggest that the fault occurred at the time of the alert, i.e. not earlier when the RA operating / display logic became valid.

The AT mode change requires a combination of flap and RA <27ft, thus in the accident the AT mode change may not have been coincident with the gear alert, i.e. it required a flap selection. The crew may have considered the gear alert as an isolated problem – possibly cured by lowering the gear. In this instance then the flap selection started the low speed event and the AT mode change; was this the same for other crews.

In comparison to an ideal operation the accident approach profile appears higher than normal (joining GS from above) and possibly fast/tight on an energy schedule; if so, the flap selection may have been later than ideal, which reduced the time for detecting the AT mode change, time which could be further compressed by the pressures of a training flight.
In other operations, did the crews have extra time, by either earlier flap selection or not suffering similar pressures of operation; - time in which to scan the flight deck and check the display. Scanning – situation awareness, and time management are aspects of CRM.
During the accident approach, it would be expected that the AT would be at idle, enabling speed reduction on the GS and deceleration with further flap selection. Did previous crews have a similar expectation, if not why not? Checking and control of expectation - CRM, discipline - Airmanship.

A problem for the accident crew was the drift from normal operations – small deviations in height (above GS) and higher speed (energy), compressed time, and in a training environment.
A Training Captain requires skill to judge how far to let a training situation drift (skill / judgment; qualities of airmanship).
All crews require similar skills of judging how far a normal operation can be allowed to drift towards the boundary of safe operation, but as our judgments can be biased, distorted, and fallible, we need to introduce constraints – boundaries or check points.
The stabilized flight path concept has constraints and check points, but these depend on discipline to adhere to the procedures – doing what we say we will do (airmanship).

As for the skills of flying, many of these come from practice and exposure to similar situations, which are the basis of experience. Without sufficient experience, such as during training, then the boundaries of normal operations must be strictly respected, even tightened to ensure that if the unexpected happens there is time to adjust and remain within the bounds of a safe operation.
I suggest that many of the safety points from this accident come from identifying the things we (industry and individual) do routinely to maintain safe operations, and from those rare occasions where we drift towards the edge of safety. We have to look to ourselves before looking too closely at others, and share best practices of normal operation and lessons learnt from the non-normal operations.

Ex Cargo Clown 13th March 2009 01:07

I'm sorry, all this CRM is wishy-washy rubbish.

The facts are that there were three sets of eyes, one may have been looking out of the window looking for the runway, but someone, ANYONE, must have spotted the speedtape dropping into the red.

There is something very wrong with all of this, you glance at the EADI for one millisecond and the speed and pitch should become apparent.

It's not a scan, it's a natural reaction.

HarryMann 13th March 2009 01:20

alf5071h

Nice post alf, IMHO

alf5071h 13th March 2009 01:29

Ex Cargo Clown there is nothing in the view that I expressed above that said that the crew did not look at the speed tape and see the low speed. As has been discussed previously, it is possible that by the time that the crew understood the low speed aspect of the situation it was probably too late to prevent and/or recover from a stall (low altitude) or that a successful recovery was marred by the failure to disengage the AT – also with complications of mistrim.

If previous crews had progressed to this point then what aspects of their behavior saved them? Your premise is that someone ‘must’ have seen the speed – unfortunately ‘must’ (the obvious) is not always the case when you involve humans.
My premise above is that if there have been previous incidents (common contributors and circumstances), then the absence of accidents implies that either those crews behaved differently or some specific point of the circumstances differed from this accident - possibly under human control. If the difference was in human behavior then we might look toward CRM and Airmanship as solutions – but not as the only solutions..

protectthehornet 13th March 2009 02:31

RA
 
the planes that I've flown had old style radar altitmeters...you know the type, an analog needle that moves....and it made a funny sort of scratchy sound when it moved rapidly, like during a press to test.

While flying along in the higher flight levels, the RA would occasionaly swing wildly from 2500plus to just 1000' or so, and the reason I saw it was the noise it made in the course of its normal operation. ( we flew over another plane it got a bounce ).

Anyway, with the modern RA's, I can imagine there is no noise in its normal movement...without the noise there might not be any alerting of the crew.

There are all sorts of old fashioned noises in planes that caused a pilot to become alert. Indeed, our open cockpit biplane forefathers said the wind whistling through the wires would warn of a stall by playing, "nearer my God to thee".

Just something to think about, loud clicks, buzzes, the whole myriad of sounds...even that lovely 400hz sound of the electrics... a traine ear can hear problems of all kinds...UNLESS they are designed OUT of the system.

Flight Detent 13th March 2009 02:37

On any approach in any airplane, speed and altitude maintenance is King...

everything else is a side issue.....

hey, Protecthehornet...sounds like a Classic 747 you've been riding in...

Cheers...FD...:ooh:

Nigd3 13th March 2009 09:48

Ex CC
Whilst what you state may be true and factual, for me the most important reason is why.
Facts do not help the aviation industry to improve safety. "Someone should have done this or that" is not that important, it's already known. Why didn't they pursue the correct course of action? Why did they think everything was according to plan when it was not? Why did they miss a critical indication? Why, why why?

idle bystander
Do you really think that the system designer is solely responsible for certifying an aircraft or system? Do you seriously think that safety assements, FHAs, FMECAs, HF testing, pilot cockpit working group decisions, FAA auditing, plus a multitude of other operational and safety justifications did not go into the design of the NG?

737only 13th March 2009 09:54

We checked that one in the SIM, the hardest to us was to look at the tape and see the speed drop. It took an awfull long time to get to the point where the stick shaker came. The pitch was amazing! Recovery was very very easy. However, once you let the A/T Retard from G/A Thrust again and fly the recovery with IDLE for 6 sec, you are bust!

Sad and unneccessary, no matter what contributed to the distraction.

bobcat4 13th March 2009 10:15

Rainboe wrote:


How can people be so arrogant that they know where a company like Boeing is allegedly going wrong?
Nigd3 wrote:


Do you really think that the system designer is solely responsible for certifying an aircraft or system? Do you seriously think that safety assements, FHAs, FMECAs, HF testing, pilot cockpit working group decisions, FAA auditing, plus a multitude of other operational and safety justifications did not go into the design of the NG?
History has proven Boeing (and others) makes mistakes like bad design. I can reel off many examples. The newest one:

Federal transportation safety officials Wednesday issued an "urgent" recommendation calling for a redesign of a component on some Boeing 777 aircraft engines -- a component blamed for two major mishaps in the past year.

Found on 'Urgent' repair recommended for some Boeing 777 engines - CNN.com

What about the famous cargo door on the 747? United Airlines Flight 811 some 20 years ago. Bad design!

So why should we believe that "This time they've got it right!" ?

And life on this thread has taught me to add: The above is not directly related to this accident, but as a comment to those who flame laymen for insinuate aircraft manufactures may make a mistake or two...


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