catplaystation - totally agree. It is clearly ludicrous to listen to the hideous lawyers charming the birds out the trees with 'proof' that night is day and black is white. Clearly, the performance of the pilots was the single biggest factor in this terrible accident. Nonetheless, given their dismal performance it would have been great to avoid a stall if technicaly possible!

EMIT - I do, of course, agree with you that the pilots are absolutely critical to a successful outcome. As you rightly pointed out through the A320 accident in Bangalore, if you have complete buffoons in the flight deck who choose to fly a totally serviceable aircraft into the ground there is only so much you can do to stop them! Nonetheless,a 'triangle of protection' can be identified - pilot performance (through screening at selection, knowledge, training, experience etc), company culture and aircraft capability. If all three are attacked then there is a way out of these types of accidents. I do accept that the A320 series is not perfect, but it is nonetheless a genuinely 'smart' machine which provides significant, but not foolproof, protections against pilot mishandling.

Norm, in defense of Boeing, reference, an A320 wouldn't have allowed this accident to happen, The A320 that crashed a year ago at Sao Paulo wouldn't have happened if it was the B737 with manual speed brakes and less automation. Their safety records are about the same but the crew flying has to fly the aircraft properly.

bubbers,

I agree entirely about the crew having to fly the aircraft.

And I'm not even so certain about an A320 in this case. Alpha-Floor protection is inhibited below 100ft RA. Which radio altimeter feeds it? What does it do when it gets "eight feet under"?

If automatic TOGA thrust were inhibited, it would still develop a high sinkrate at very high angle of attack. It may have hit the ground, tail first, just as badly, even if not technically "stalled". As Feynman said, "You can't fool nature", and the low-energy state of the aircraft will remain thoroughly unimpressed by computers.

The only thing that will impress it is to convert some chemical energy (fuel) into kinetic energy (speed).

Here as at Habsheim, that happened too late and/or too little.


On the other hand, B737s also had runway overruns at Sao Paulo, just not as catastrophic.

It is dangerous and complacent to say "This accident couldn't have happened in Aircraft type X".


Bernd

fireflybob made some cogent remarks in post #1871 re situational awareness. There are those seemingly trying to discredit the NASA study, but it still holds water.

New Definition of Pilots error
 

"Sterns said the Turkish pilots had no fault in the accident, as evidenced by the nonexistence of any fire or explosion."

So this is the new definition for pilot's error? :ugh:

Regarding SOP for Stall Recovery my AOM indicated as first actions:

- ck A/P & A/T off
- ck G/A power established
- ck Spoiler retracted

All of this to be monitored by PNF

If you'd hit a wall with your car, can you blame the car producer for not writing "You must apply brakes in order to not hit an obstacle." into the cars manual?

Quite, as mentioned.

Full power. Selected via G/A and or manual. Always confirmed via manual backup.

Airbrakes. Closed.

Decend / Level flight.

Increase speed, stall recovered. Climb. Climb. Climb.

Problem was, this happend at such low alt. Was there enough time for any of this to happen.

They got full power, they didn't have level flight.

The problem was noticed at a very late time, a time which was clearly too late to recover.

Big shame.

Read what really happened with the recovery attempt!

THY... surface wind ___/___, cleared to land at N4320.4 E00510.4

Some comments to the last few posts,

@ Towerdog, the high stress environment I was refering to was not the approach in good weather, but the stickshaker going off (completely unexpected) at low alt combined with several warnings (AP disconnect, GPWS etc). We can discuss that in all length, but to me that would be high stress.

@ BOAC, You are right, you're recovery procedure is the same as in my FCOM, Setting full power by the PF, to be monitored by the PM. If the AT subsequently pulls the PL's back to idle, you obviously haven't set full power. I agree with that!!

However, I can imagine that the lawyers will have a field day with it . PM me if you want, I'm willing to wage a small bet that once the dust has settled and law suits have been completed that boeing will quietly come out with a small amendment to the stall recovery procedure in the FCOM.

@ Flying heavy, Strangely enough there seems to be some differences in FCOM's. Mine doesn't say in the stall recovery to disconnect the AP, AT. Just to apply full thrust. It even has a note stating that if the AP is on to leave it on and allow the airplane to return to normal speed, followed by a second note that if AP response is unacceptable to disconnect the AP.

Just to be sure, I don't fly a A/C with the book in my lap, common sense is implied, just pointing out what the book says, because that's what the lawyers will do.

In my account of what happened I made a small mistake, I said the A/C intercepted the gs, the gear was lowered and flaps lowered, then the RA fault. This was wrong, the gs was intercepted and then the fault occured or the gear warning wouldn't have happened, my mistake.

I still think a stall warning at low alt is very stressfull, almost all emergencies, faults etc can be programmed. An unexpected stall cannot ( at least I think it cannot, I can be corrected though) Windshear at low alt, engine failures, RA's even unusual attitudes (had a scenario in the sim were we encountered wake turbulence wich threw the ac nearly inverted). Stall cannot be programmed though. I can still see how the FO pushed the PL full forward (with the NG that's all it takes) and pushed the yoke forward, the captain taking over at that moment (can't fault him for that, I think every captain would take over), him fighting the yoke monitoring the attitude display with all the bells and whistles going off in the background and the AT pulling the pl's back again.

Once again, I think there's nothing wrong with the automatics design, I don't think it was a high workload/stress situation. However the crew allowed it to became a high stress situation. Most pilots would have never allowed to get that far, but I wonder how many guys, once they got to the unexpected stall at low altitude would have made the same mistake. It's not a subtle hint that most guys would have made the same mistake, I only wonder how many guys would have.

German AOL...
 

AOL puts up little snippets of news on the home page (I think it is called) you get when you log on to select e-mail.

There is an article running now about this crash, really addressing the very different ways it is being viewed back in Turkey and around the world. They don't mention PPRuNe by name but I wouldn't be surprised if they are watching which way the comments run.

They even brought up the way Turkish comments have dragged Islam into it by mentioning the way an animal was sacrificed on an airport ramp back in the home country, as if to say that the ground engineers were all bumpkins. Turns out that wasn't Turkish Airlines at all but never mind that now...

I really, really think that it is a good idea to skip this morbid guessing game every time there is a high-profile crash.

Once the cause is known, by all means publicise that so that we can all profit by learning from the mistakes of others but this jumping in with wild guesses about everything from fuel exhaustion to wake turbulence to pilot error; what good does that do? In fact, I think it really damages the image of the profession to show some of us putting the boot in before the facts are known.

- I'm sure you are right, sadly. I was merely trying to point out that it is really NOT Boeing's fault if pilots do not fly properly. It is the way of the world, I fear, and why my cardboard coffee cup says 'Warning - contents may be hot"

I think speculation about the causes and circumstances of accidents are good. They inspire one to think about all the possibilities, tricks and traps.

One person cannot know as much as everyone put together.

GB

I don't agree...
 

Whenever I look at these threads it always reminds me of that stupid, funny Hollywood movie about the police, "Police Story," I think the title is, the one with Leslie Nielsen and O.J. Simpson when he was still taken to be a nice guy.

There is a scene in the movie where Nordberg has been shot and Lt. Drebbin is speculating about the possible motive for his shooting in earshot of his wife. We are watching her reactions to his "thinking out loud" as he says something like, "perhaps it was a jealous boyfriend..." Funny in a funny movie, seeing someone play an insensitive total clot, perhaps not so funny in real life, especially for the survivors of an accident.

Here you often get people making total fools of themselves by showing that their expertise stems from Microsoft Flight Simulator or else just taking some W.A.G. and running it into the ground without any relevant facts to go on except that, yes, an aircraft has crashed in somewhat unknown circumstances.

There's always a lag between the event and the report, about a year to a year and-a-half, the time it takes for the event to be researched, the results analysed, the report to be written, reviewed, approved and published. This final report is what we really need to pay attention to, though, not the scuttlebutt we hear or generate around the coffee machine!

I remember very well one high-profile crash when I had inside information about what had happened, that they lost their hydraulics and went in out of control. My informant knew the guy who had snagged the aircraft, the crew who had refused to fly it and the guy who then took it on its fatal flight. All very, very interesting and totally wrong! The airplane went in having been mishandled, with nothing technically wrong that would contribute to the crash. All that rumour-mongering was just us chasing a red herring!

This stuff, to me, is very like the "rubber-neckers" who drive past a nasty crash gawking at the wreckage, indulging some morbid urge. There's almost nothing of value in it if you think, as I do, that the final report is the only thing that really matters to most of us.

Just think about all the people who, to this day, pontificate about that Swissair crew and their adherence to a checklist when they should have... blah, blah, blah. Read the report to see that they were basically doomed for technical reasons, that their actions did not cause the accident. There you have people just unthinkingly condemning a crew when they really do not know what they are talking about and cannot be bothered to learn the rather boring facts.

This one at Schiphol, how many people had already nailed their colours to the mast by telling us the cause of the accident when almost nothing was known. Turks are lousy pilots! No, they ran out of fuel! No, it was wake turbulence! Poor maintenance. Politics. Religion, even... You really think this is useful? I don't.

Don't let me stop you in this playing "Crash Investigator," of course. What do I know, really? I have got to that unhappy state of "the more I learn, the less I know!"

So Chucks, your post begs the question. Why are you here? After many hundreds of posts too, I note.

Well, allow me some surfing on the off-thread wave for a little while.

I just can't understand some people here…
Just as long as your reading abilities aren’t impaired by any circumstance and your brain is still able to filter the information that suits your curiosity from the background noise, and if it’s not too difficult to read all the posts in the thread, what is really the problem?

I can dispense some reading techniques for those who have trouble in finding the right answers to their questions, but basically it all comes down to find that half-a-dozen long time ppruners with excellent credibility (proven along their pprune existence over the years) in between the surrounding clutter, but allowing the eye to drift for those posts belonging to unknown users, or those whose participation is scarce, because sometimes there is good and sensible information there. Others are just silly and make you laugh. All the rest is bypassed or ignored.

All in all it takes minimal effort to do this type of positive filtering, with the bonus hard work of the mods, cleaning after a lot of poo-poo posts. So what’s the big deal!

These people could criticize Leo Tolstoy about the length of War & Peace. Ah bless ‘em. :ugh:

GD&L

It is Chuks, actually...
 

Only one "c" because it is short for something African and much longer. Never mind that now, though!

An alert reader asks "Why am I here?" Good question, well put. Check back just a few posts and you will see that I passed along the reaction to this sort of thing, all this speculation and mud-flinging, even, on AOL Deutschland. That is about it, really.

I am an avid reader of accident reports, often getting something from them that I can use, going by that maxim that we should learn from the mistakes of others because we will never have the chance to make them all ourselves. Well, that or it might be that many mistakes are deadly, with the mistake-maker ending up dying as a consequence!

I enjoy a bit of dialogue, discussion, whatever but this post-accident stuff often starts as rumour-mongering and narrow-minded argument from preconceptions and then somehow manages to go downhill from there!

This is "thread drift" so that I shall now gather up my petticoats and disappear before I get chucked out, leaving you all to the dissection of this accident. Perhaps we should get together sometime in 2010 to see what the official report says.

Chuks,
Thank you for your courteous and valid explanation. My apologies for misspelling your name.
Paul.

100 seconds at idle thrust; what were the crew up to? It seems to me a lack of old fashioned monitoring of the IAS and FMA. RETARD in big green letters!!!! dbee

Something to read
 

Just something to read:

Aircraft Emergency Management During Approach

This is from Airbus, but still gives some ideas.

That was my thought early on, but what little hard evidence we have so far seems to say T/L's were at idle, and engines running (stabilized?) at idle, for 100 sec. before recovery was attempted. Isn't that inconsistent w/ fuel starvation?

They were an average crew on an average day. If we say they crashed because they were stupid then we are doomed to a repeat.

Fuel starvation was not the case, this preliminary conclusion comes from the reading of FDR recordings. I do no more see the point as to why to take space with such wrong (not only unfounded) speculations on a Flight Deck Forum!
And that is for you RA!
Clearly, I got it too.
On the first pages of the thread, from what I could see of the condition of the fan blades, I thought Fuel Starvation could have been the case (modest angular velocity at the time of impact). But this was proved wrong.
Now, I would advise to keep on checking here (there are also telephone numbers, so I guess -- again -- that any of you who has the right credentials and qualifications, and is really interested, could get a strictly confidential anteprima):
Crashed during appraoch, Boeing 737-800, Amsterdam Airport Schiphol - De Onderzoeksraad voor veiligheid

Cheers to you, BOAC.
Paolo

Nicely said. But how does reality look like ? Basic flying training is reduced every year.
(the introduction of MPL is reducing actual flight hours in our ab initio training by another 30 % after it was already recuced by 50 % since the end of the 80´s in my company) No problem, because we have ´smart´ machines ? The statistics show the opposite.
How can we avoid a loss of control accident ? Some more computers, or some more protection modes (...which of course will cause other accidents - f.e. Quantas 330). Or would it be smarter, to invest again in a pilot who can control pitch and power ?
On line training wouldn´t cost anything, btw.

Am I missing something here, Boeing have published the probable cause and the recommendations to 737 operators over a week ago!
God help us if some of the contributors to these threads get anywhere near a real aircraft, other than as a passenger!

TECH Bulletin 737-09-2-R1

Ok, one could ask why no one was monitoring the thrust levers or speed decay, but that would be guesswork.

- probably not, but we are! Can you post that Tech Bulletin here?

Here you go!

BOEING COMMERCIAL AIRPLANE GROUP
FLIGHT OPERATIONS TECHNICAL BULLETIN
NUMBER:
DATE:
737-09-2 R1
March 30, 2009

These bulletins provide information which may prove useful in airline operations or airline training. This
information will remain in effect depending on production changes, customer-originated modifications, and Service
Bulletin incorporation. Information in these bulletins is supplied by the Boeing Company and may not be approved
or endorsed by the FAA at the time of writing. Applicable documentation will be revised as necessary to reflect the
information contained in these bulletins. For further information, contact Boeing Commercial Airplane Group,
Chief Pilot, Flight Technical, P.O. Box 3707, Mail Stop 14-HA, Seattle, WA, USA 98124-2207, Phone (206) 5449610,
Fax (206) 544-9687, SITA: SEABO7X Station 627.

SUBJECT: Flight Crew Monitoring During Automatic Flight

ATA NO:

APPLIES TO: 737 All

Background Information

An erroneous Low Range Radio Altimeter (LRRA) has been identified in connection with
a recent 737-800 accident.

The Digital Flight Data Recorder (DFDR) data indicates that the crew was using both the
autopilot and the autothrottle during an ILS approach. The right LRRA was providing
accurate data to the first officer’s display and the left LRRA was erroneously providing a
reading of -8 feet to the captain’s display. No amber RA flag was displayed because the
left LRRA system did not declare the data invalid.

On all 737s, the autothrottle logic uses left radio altimeter data if the left radio altitude is
being displayed. This is regardless of the autopilot selected. On the 737NG, if the left
amber RA flag is displayed in place of radio altitude, the autothrottle will use right radio
altimeter data instead. On the 737-200 and 737-300/400/500, the autothrottle computer is
only connected to the left radio altimeter; therefore, if the left RA failure flag is displayed,
there will be no radio altimeter inputs to the autothrottle.

In this event, when the airplane descended through approximately 1950 feet on the
approach with flaps extended beyond 12 ½ degrees, the autothrottle erroneously sensed
that the airplane was in landing flare. The thrust levers were retarded to the idle stop
where they remained for approximately 100 seconds. For the first 70 of the 100 seconds,
idle thrust was sufficient to maintain the selected airspeed. During the next 30 seconds,

Page 1 of 4


airspeed decreased below the selected MCP speed to approximately 40 knots below the
selected approach speed.

The two LRRA systems provide height above ground data to aircraft systems which
include the displays, autothrottle, autopilots and configuration/ground proximity warning.
If one LRRA provides erroneous altitude readings, the associated flight deck effects may
typically include:

•
Large differences between displayed radio altitude.
•
Inability to engage both autopilots in dual channel approach (APP) mode.
•
Unexpected removal of the Flight Director Command Bars during approach on
the pilot’s side with the erroneous radio altimeter display.
•
Unexpected Configuration Warnings after takeoff, during approach, or during go-
around.
•
Inappropriate Flight Mode Annunciation (FMA) indication of autothrottle
RETARD mode during approach phase with the airplane above 27 feet AGL.
There will also be corresponding thrust lever movement towards the idle stop.
The FMA will continue to indicate RETARD after the thrust levers have reached
the idle stop rather than change to ARM.
Boeing Recommendations

Whether in automated or manual flight, flight crews must carefully monitor primary
flight instruments (airspeed, attitude etc.) for aircraft performance and the FMA for
autoflight modes.

The following information is taken from the Flight Crew Training Manual (FCTM) and
has been adapted to provide Flight Crews and Operators with guidelines which should be
followed if a flight crew encounters any of the above mentioned indications.

General Guidelines

Condition:

•
Large differences between displayed data.
Crew Resource Management (CRM) involves the effective use of all available resources
to operate a flight safely. It is important that all flight deck crewmembers identify and
communicate any situation that appears potentially unsafe or out of the ordinary.
Experience has proven that the most effective way to maintain safety of flight and resolve
these situations is to combine the skills and experience of all crewmembers in the
decision making process to determine the safest course of action.

Situational awareness, or the ability to accurately perceive what is going on in the flight
deck, requires ongoing questioning, crosschecking, communication, and refinement of
perception.

Page 2 of 4


Condition:

•
Inability to engage both autopilots in dual channel approach (APP) mode.
•
Unexpected removal of the Flight Director Command Bars during approach on
the pilot’s side with the erroneous radio altimeter display.
•
Inappropriate Flight Mode Annunciation (FMA) indication of autothrottle
RETARD mode during approach phase with the airplane above 27 feet AGL.
There will also be corresponding thrust lever movement towards the idle stop.
The FMA will continue to indicate RETARD after the thrust levers have reached
the idle stop rather than change to ARM.
Automatic systems give excellent results in the vast majority of situations. Faults can
occur at any point during an automatic approach. Many non-normal situations or
scenarios are possible. The flight deck is designed so that a quick analysis and decision
can be made for virtually all non-normal or fault situations using the autopilot/autothrottle
indicators, FMAs, master caution system and, for fail operational airplanes, autoland
status annunciations. Deviations in intended flight path or unexpected thrust lever
movement may also be an indication of an automation fault.

If the flight crew is aware of a degraded Autopilot Flight Director Systems (AFDS) mode,
special recognition should be given during the Approach Briefing as to how to manage the
use of the automatic features.

Note:
Early intervention prevents unsatisfactory airplane performance or a
degraded flight path.

When the automatic systems as described above do not perform as expected, the PF
should reduce the level of automation to ensure proper control of the airplane is
maintained.

The PF should not attempt to restore higher levels of automation until after aircraft
control is assured.

Condition:

•
Unexpected Configuration Warnings after takeoff, during approach, or during
go-around.
Flight crew must ensure the proper configuration for the phase of flight. Time may be
required in order to assess the situation, take corrective action and resolve the
discrepancy; therefore a go-around, holding, or additional maneuvering may be
necessary. Flight path control and monitoring of instruments must never be
compromised.

Page 3 of 4


Non-Normal Situation Guidelines

When a non-normal situation occurs, the following guidelines apply.

•
NON-NORMAL RECOGNITION:
o
The crewmember recognizing the malfunction calls it out clearly and
precisely.
•
MAINTAIN AIRPLANE CONTROL:
o
It is mandatory that the Pilot Flying (PF) fly the airplane.
•
ANALYZE THE SITUATION:
o
Any further action should only be initiated after the malfunctioning
system has been positively identified.
Additional Information

Any occurrences of erroneous display data, even if intermittent, should be reported to
maintenance.

More information can be found in the Boeing 737 Flight Crew Training Manual and
Flight Crew Operations Manual. Operators may want to review the following:

737 FCTM

1. Chapter 1 - Crew Resource Management
2. Chapter 1 - Callouts
3. Chapter 1 - AFDS Guidelines
4. Chapter 5 - Approach Briefing
5. Chapter 5 - Stabilized Approach Recommendations
737 FCOM

1. NP11 - Autopilot Flight Director Systems (AFDS) Procedures
2. Chapter 4 - Automatic Flight System Description
3. Chapter 10 - Flight Instruments, Displays System Description
4. Chapter 15 -Warning Systems System Description
Page 4 of 4



So the main point of Boeing's report is: Pilots must monitor their screens. But surely this is so horribly basic, its like saying a car might crash unless the driver looks where they are going?

You are wrong. This is the main point:

Not at all. The pilots are there to push a few buttons and program the flight computer. The automatics do everything else.:rolleyes:

from the report:

Owww....shocking.

also:


This could be a nice one. if Turkish airlines is accustomed to leave the A/P on in all circumstances, how are they going to deal with this Boeing statement?

"pilots are there to push buttons...... and the automatics doing everything else."

Berganair B757 out of the Caribbean. ADC LHS failed on takeoff below 80kts. Capt decided to continue and trouble shoot in the air. F/O PF and all on RHS was OK. Engaged C autopilot as standard. It was connected to L ADC. Oops. A/c stalled under command of the automatics and a/c performed barrel roll into the sea. The automatics sure as hell did everything else on that day. Oh dear! Once again a 99% serviceable a/c crashed, all died due to lack of PF flying the a/c, analise the problem and then the unusual scenario can be diagnosed before attaching the flying a/c to the automatics which were not behaving normally. Of course it would have been better to abort the takeoff and discuss it in the bar.

Often the automatics can reduce the workload/stress and allow a relaxed analysis, but the need to be used with care, certainty and monitored constantly in these circumstances. Shades of the L1011 down in the Everglades as well. The circle keeps turning.

llondel is just showing his British sense of humor.

Reminds me of the oil guy that came to the US, bought a $300,000 motorhome, got on the turnpike, put it on cruise control went to the back to get a drink and crashed. He sued because the manual didn't say cruise control only controlled speed.

There was a leakage path in the radio altimeter antenna system that caused the -8 feet indication. At some point on the approach, valid ground return would have been enough to overcome the signal strength of the leakage path. That's why erroneous radio altimeter indications don't show up at the gate, and require more than "black box swapper" skill to troubleshoot.

Did the #1 radalt start working correctly again at, say 1000 feet? If so, would the A/T have cancelled the Retard indication, or was it latched into a Retard logic routine? If the A/T logic had reset, the A/T would not have left the throttles at idle.

GB

Swapping RAs left vs right would have led to the news that it was not black box trouble, but rather in the left cable or antenna. I thought all techs employed this old, old method of sorting things out.

Turkish 737 mistakenly lands at Georgian military airport
 

Many thanks, KG:

- I have to take you back a step, as you are assuming that
- took place. As fox niner points out, "It is mandatory that the Pilot Flying (PF) fly the airplane." and, of course, that the other pilot monitors, and even more importantly, in a training environment, that the TC is on the ball.

I note no comment there about the attempted recovery from stick shake. That surprises me, unless of course our info so far is incorrect.

:

What was the 'non-normal?

RA information was irrelevant to their approach and it seems likely (and even understandable) that the captain did not notice it was reading -8ft. Remember that there was probably no fault warning. Even if he had noticed it is possible he did not mentally connect that with any effect on the A/T as this involved fairly esoteric system knowledge.

The non-normal was therefore the inappropriate enunciation of RETARD and the failure of the A/T to apply power when required.

Just thought I would clarify that.

NO - the NON-NORMAL was a speed 40kts below Vref which in my book is a bit unusual in the air.:ugh:

BOAC

I think we agree

Retard + no A/T response + no crew reaction = Vref - 40

What I was trying to clarify was that the RA fault was not the decisive 'non-normal' before we get more endless discussion about the RA system.

763 Jock, what to say , really , nothing to add. :rolleyes:

What does it say on your contract " Pilot" ? :confused:

Basic description of job ? keep large chunk of aluminium containing human life in air from A to B. :D
Feel free to use any bits of technology found in aforesaid bit of aluminium, but don't forget that YOU are employed to point aforesaid vessel in good direction at all times.
I think Boeing are showing WAY WAY beyond the level of political correctness I would employ ( no doubt with a legal stance in mind)
YOU are employed as a PILOT, do you mind ( PLEASE) to perform the function we requested (BASIC ONE) if you wish to collect a salary at the end of the month ?
End of message.


DUH. . . . What is the job ?


Uh? . . . . I am a pilot :ok:


Mmmn, what does that involve ? :8 Duh :rolleyes:


Well, Ermn ' Well. :confused: Well I think it involves taking that chunk of aluminium from A to B without hitting anything on the way, is that OK ?