Well if the conclusion of this report is that it was all Boeing's fault it's time for me to retire and never travel as a passenger in an a/c again!

Further evidence of the death of critical thinking.

I generally do not contribute to threads any more, but I am somewhat exercised by some comments and comparison to BA038. I do have something to say about TK 1951 as well (see bottom).

First, BA038 (sorry for thread creep but I do want to be clear on this in a forum in which it has cropped up).

Professor Jim Reason gave an invited talk at the 4th IET Conference on System Safety in London in October 2009, in which he talked about what was known and not known about human factors in safety-critical systems. Many here will be aware that Prof. Reason has been a major influence on human factors thinking in aviation in the last three decades or so, indeed the ATSB (or BASI as the aviation part was known then) based their accident analyses on his classification system for many years. He described two views of operators in critical systems: "human as hazard" and "human as hero". He organised "heroic recoveries" into four categories: "training, discipline and leadership"; "sheer unadulterated professionalism", "skill and luck", and "inspired improvisation". He had six examples of "sheer unadulterated professionalism": Captain Rostrom's action for the Titanic survivors (1911); Apollo 13 (1970); the BAC 1-11 incident of 1990; BA038; and United's water landing on the Hudson River. He said that what it comes down to is "irreplaceable people": "the right person (people)"; "in the right place"; "doing the right thing"; "at the right time".

I agree with Prof. Reason, in his words, that Captain Peter Burkill, along with his colleague First Officer John Coward, is one of those humans as hero, exhibiting sheer unadulterated professionalism, one of the right people, in the right place, doing the right thing, at the right time.

Unknown to Jim at the time, I had invited Captain Burkill to participate in my keynote talk to the same conference later that day. Peter came at lunchtime just after Jim had to leave - Jim asked me to convey his regards.
I had allocated about ten minutes at the end of my talk for Captain Burkill to tell the assembled engineers what it was really like being at the pointy end of all that. The audience was fascinated (Peter is also - obviously - a compelling raconteur) and the session chair, Carl Sandom, let the time run over for about 15 minutes, because of the questions and answers from the audience, not to speak of their rapt attention.

I just wanted to make it completely clear here what people such as myself, Prof. Reason, and my colleagues working in System Safety think of the performance of Captain Burkill and First Officer Coward. We applaud it.

As far as I am concerned, S.F.L.Y. is welcome to remain in his comfortable minority of one.

Second, TK 1951, the topic of this thread.

I am familiar with the human factors investigation and what the conclusions are. The HF investigation was led and the report written by a friend and colleague, who besides having a world-wide reputation and being in my judgement one of the top five aviation human factors analysts is also a practicing 737NG pilot. So concerning TK 1951 he knows whereof he speaks.

It is a fine piece of analytical work, subtle and eye-opening (at least for me) and I recommend that everyone read the report when it comes out. The analysis does not actually fit any specific one of the views aired here (including my original view). There is something to learn for everyone (as there was for me).

I might point out, as many already have, that concepts such as "responsibility" and "blame", the things that people here are suggesting that journalists wrote about the forthcoming TK 1951 report, are not used in ICAO-standard accident analysis and reporting and I sincerely hope that they never will be. It is hard enough to get the causal stuff straight without mixing in the legal as well. Most lawyers I know are equally happy to keep them separate; it makes their tasks easier also.

PBL

Sorry about what you read as sarcasm there, PJ2. It is just that, as you are no doubt aware, a student pilot should be taught about a lot more than just keeping the airspeed above a certain critical value so that one really cannot say that "Airspeed is Everything," and leave it at that.

Seriously, you could tell some unfortunate that and have him thinking he's in good shape in his little Cessna with 90 knots on the ASI but -1500 fpm on the VSI. If he survived that one his come-back would be, "But you told me that Airspeed is Everything!" when you would then have to try to over-ride the Rule of Primacy, when whatever you had told him first would be very firmly believed. Good luck with that!

I have had people getting their knickers in a twist when I have got all the way down to Vref on an approach, when they want to see Vref +10 or whatever they have been told is the minimum safe value carried all the way to the 50-foot point. There, in my opinion, they are placing far too much emphasis on speed alone, ignoring many other things of equal import, plus forgetting that Vref already has a 30% speed margin above stall built into it, 30% that you will have to get rid of before the airplane stops flying, usually in ground effect.

Speed awareness seems to have played an obvious role in this accident, given that we have been told the accident crew got to 80 knots there. I really do look forward to learning how this happened, when whatever the cause is given as must be taken as "plausible" even if it's also "improbable, incredible, unbelievable" or whatever else we loosely call something very, very surprising.

Who would ever have guessed that an FO would raise the flaps unbidden as the response to a stall, yet that is exactly what happened in that Colgan Buffalo accident. It is, yes, very "implausible" that any pilot would do that so that we have to try and figure out "Why?" if that is possible.

As pilots there's always a defense mechanism that comes into play when there is an accident. We want to dismiss the accident crew as exceptional, as if to say that whatever happened to them will not happen to us. "They weren't watching what they were doing!" when we, of course, always do. Yeah, except when we don't, and if there are a few other factors in play then we too might have an accident. So I think we have to wait for the report to read it carefully, put ourselves in the shoes of the dead crew and think our way through what went on there. Or we can just go into self-defensive Sky God mode, assume we could never make such an implausible mistake and carry on as we are.

One of the most Sky Godly of us all, one who was always ready to dance on the corpses of other accident pilots, made a deadly mistake of his own one day. When I heard about it (when I knew him, the airplane and the environment that killed him) I thought to myself that if he'd been a bit more open to the idea that he too could make some obvious screw-up then he and his three passengers might still be with us.

Thanks for your open minded contribution. I obviously don't understand which performance you are applauding. Reacting to speed decay by increasing AOA is definitely a very unique and innovative performance... and applauding it is another one!

single channel retard?
 

If my memory not fail the autothrottle flare retard mode is only a double channel ILS app.This plane was in single channel (B)

Leave BA038 out of this thread
 

By expat400
Just the best short answer on this thread so far! Agree 100%

By PBL
Just the best long answer on this thread, a complete delight to read sir!

BA038 has been done to death on it's correct thread do we have to here?
I will never falter on my belief that the BA 038 cockpit crew are hero's! I wish that some contributors be a little more positive towards the aviation industry instead of all the "what ifs" with out foundation in many cases flooding the threads. :ugh:

Sorry, cessnapete, but those points are wrong!

I'd prefer not to drag out 038 here (PM if you wish), but the defect was not recorded and therefore no MEL action.

S.F.L.Y.
 

SFLY is a wannabe and UAE apologist, just check his previous post, especially in the Middle East Forum.

S.F.L.Y
 

The difference is that the BA038 crew was never trained for the "glider landing" situation, so there is no way you can demand that they should have known about best glide speeds. In contrast, the TK crew could have either just pushed the power levers or pushed the nose down for speed, before it was too late, but did neither despite they were most certainly trained for that situation. :oh:

As far as I know, they did (or one of them) gave GA trust to recover (when the stick shaker came in), but the lever went back to idle again and that they didn't notice untill too late (low).

Check all my previous post if you have nothing better to do and can't elaborate on factual and technical issues.

I'm just sorry to read that in one case pilots should be considered a heroes while in the other they should be considered as zeros. This attitude is purely ridiculous and unprofessional.

To me situations were quite similar: automatic approach, lack of thrust, speed decay and no effective action to stop the AOA to increase to insane levels. In both cases aircrafts reached stick shaker without thrust. The only difference was the available height for recovery, nothing to do with heroism.

When you have no speed and no thrust you simply don't increase your attitude, that's very basic and easy to understand. 15 years old teenagers flying gliders know that they shouldn't pull on the stick if they're short on final. How does it differ in a 777?

Have the decency to stop blaming one crew while throwing roses at the other when the outcome of these accidents are only based on available height after stick shaker activation.

Turkish airliner crashes at Schiphol
 

Because they were fighting to push the conrol column down. Due to gradual speed decay the pitch trim was maxed out and aircraft was trying to climb..During this struggle the throttles went back to idle.

S.F.L.Y.

I am going to bed now, so don't expect a response in the immediate future.

Stop comparing the Turkish accident with BA038.

The difference , in case you somehow failed to notice, is that one crew were handed an impossible set of circumstances at 500ft and (according to you ) failed to optimise the glide performance of a Boeing 777, and horribly let the pilot population down by doing what 99.9% of us would do, by trying to avoid having a windscreeen full of suburbia as they tried to arrive somewhere on Thiefrow. Funny how anyone with a professional qualification and experience seems to think they did a bloody good job, where does that tend to put YOUR opinion shag ?

The "other" crew regretably, somehow, failed to notice or react to the fact that their cfm56's remained at idle thrust whilst their airspeed went West, and that in lieu of the autothrottle ,it was a good idea to react. Whilst there is sympathy for their error,and a desire to understand what may indeed have contributed to this almighty cock -up, opinion seems to be "what the hell were they looking at? " Again , where does that leave your learned "opinion " vs the experienced professional pilots posting on here?

I am sorry to say,your bitterness and constant harping on about the safety medals the pilots both so justifiably received , labels you a prize tw@t in my eyes, and your inability to see beyond this mindset combined with your posting history deprives you of any credibility.

"You are the weakest link in this thread, Good Night"

Aerodynamic is a science, nothing to do with my personal credibility or your "experienced" aviator friends.

Increasing AOA on an engineless aircraft below Vref is severly reducing the gliding distance, that's a fact which can be confirmed by any non-qualified, non-rated, non-professional, non-credible glider pilot or C152 instructor.

Now if you like to think that in the heavy metal world rules are different and that aircrafts actually glides further at max AOA it's up to you. No need to bring the suburban jungle in the topic, ILS procedures are fortunately designed with OCH and you won't smash a building each time you slightly deviate from GS.

True, for a "stabilized" flight path.

Not true, if this energy is used to get it over the fence...
:ok:

Which fence had to be jumped 500 ft agl? Finding yourself with no more available energy at 98kts and 12 degrees nose up will only take you down at 2,500 fpm.

S.F.L.Y.

Easy to coldly apply a slice of the sciences to measure but one strand of an event when you intentionally observe through a keyhole.

Your room must be awfully tidy.

chuks;
I make the assumption here that I am writing to colleagues - to professionals who have an overall comprehension of aviation if they indicate they are licensed, and if licensed in the airline/heavy transport industry I assume experience in doing the work. I read in your bio that you had an ATPL so presumed that you would understand what is meant by the phrase I used and the way I used it.

Clearly, there is a wide variety of skills involved in flying an airplane, but it is a fundamental principle as you know, that keeping one's airspeed on the right side of the ledger is key to everything else, but that such primaries do not sacrifice everything else that one does to keep an airplane aloft and safe.

It is from that POV that I make the observation that for a professional crew to permit airspeed of an airliner to drop below Vref under any circumstances other than complete incapacitation or hijack, and down to near the 80kt range (I am led to believe), is, to put it mildly, something to examine and discover why.

I think the points you make in your response are really worth making - I have had the same experience - the 320, 330 and 340 all "sit on Vapp (Vref+5) and its a natural reaction when the airspeed is "right on bug" to wonder about the margin but your assessment is spot on. That said, at the risk of a bit of drift, I wouldn't hang on the bug in turbulent weather or with a tailwind in a 320 or 321 - its a recipe for a hard landing or a tailstrike, interestingly - it's in the data, but given your remarks I suspect you know this. Thanks for the comeback.

PJ2

Point taken...
 

I think there are more amateurs (in the best sense of that word, those who love flying without necessarily being professionals) here than you might assume, just given by the tenor of the posts, so that I am uncomfortable with such a sweeping statement about speed being paramount. There's a lot of truth in that but it really needs that overview that broad experience brings, as you have pointed out.

You can see people take stuff they read (when it must be true) and embed it in their scheme of values. Often a situation develops with some misunderstanding just sprawling across the aviation landscape like kudzu that should have been uprooted to begin with.

Anytime a perfectly serviceable aircraft is destroyed with loss of life then, yes, we can almost hope that a mistake was made that we can learn from so as to avoid the same thing happening to us. I just don't like to see this distancing mechanism come into play, even though it is only natural, that "This isn't going to happen to me because I am not (insert reason or reasons here)!"

To criticise that BA crew is breath-takingly arrogant. They lost both engines on short final yet managed that to the point where everyone survived and most people even walked away yet someone can carp about how that was achieved? If this were a TV show it would have "Warning! Kids: Don't try this at home!"

Do you mean there's nothing to learn from the BA accident? I really don't care about judging the crew, I'm interested in the mechanisms that led them to do what they did (or didn't). Pretending all what they did was perfect is also very arrogant. (just like the "I only listen to Phd holders" attitude).

Any glider pilot perfectly knows that on high aspect ratio wings slights speed deviations from best L/D have larger effects on the gliding perfs. High deviation below Vref caused by the AP attempt to land a thousand feet beyond rwy threshold couldn't deliver best gliding distance. I'm not judging the crew as I'm only interested in knowing why performances have been limited. I'm valuating comments based on their content, not on the "prestigious" degrees held by the posters.

I don't see much difference between the two incidents (in terms of human behavior). Here is why:

1 Both aircraft were on automated approaches
2 Both crews noticed speed going below Vref and both attempted corrections with thrust adjustments
3 In both cases these thrusts adjustments were infective and speed kept decaying
4 In both cases aircrafts lost the same proportion of speed and reached stick shaker while the AP attempted to remain on the ILS.

Whatever were the causes, step 4 was reached by both crews through similar processes. At that point (4) both aircrafts can't anymore follow the ILS. At that point it's just a matter of pilot inputs and trim position...

The 777 had enough height to drop the nose and recover some energy to control the impact. In the 737 the combination of nose up trim and max thrust pitch up momentum probably limited a similar nose down recovery leading to high Vz/high AoA impact. The trim positions reached by the AP in both aircrafts could have made a big difference in the outcomes. I don't see how so called "professionals" can decide whether one crew is to be blamed and the other one to be congratulated for the few seconds following step 4 since they had similar behaviors during the preceding steps.

S.F.L.Y., so you think the crew on the Turkish incident noticed the speed going below Vref? Then why didn't they apply additional thrust at a much earlier stage?

S.F.L.Y

I am not sure what kind of axe you are attempting to grind, but you seem to be alone in your effort to do it with a blunt object!

From the information currently available, it appears to me that the BA crew responded to an actual loss of thrust in the most appropriate manner by retracting the flap setting to enhance the glide performance, thus bringing the AOA closer to that for "best glide." I suspect that they did not have sufficient height to achieve the ideal AOA for the a/c weight and configuration, but their reaction to a scenario for which they had not been trained certainly improved the glide performance by some degree - and probably by just enough to change the outcome.

The Turkish crew, based on what has been published to date, appear not to have responded in any way to a situation that was unfolding gradually over a period of 100 seconds. The Turkish crew also had thrust at their disposal should they have deemed it necessary to use!

Well, you try this and see how well you do!
 

You can nitpick all you like with "coulda-shoulda-woulda" in either case and come away telling anyone who will listen to you how you would have done this so much better but many of us will just think, "Oh, really?"

I have been on a few sim sessions with some self-nominated "ace of the base," someone ever-ready to jump in with a critique of the minutiae that went overlooked in managing a serious problem over a very short span of time by some other crew. Then our ace gets handed a surprise of his own, when he shows that he too might not be Superman, when this sad fact is not a surprise.

I happen to have a Commercial Glider License so that I think I know a bit about gliding flight and in a glider I hope I can apply those principals properly. On the other hand I also have an ATPL so that I think I know how to do a powered ILS approach, although I have never flown such a large jet as a 777. Just where in these two very different things is my qualification and experience suddenly to switch from a powered to a gliding approach on short final in a large jet transport aircraft, though? What that BA crew was faced with was so far off the scope that its very probability is not accounted for and simply to have managed a safe landing was an extraordinary feat, hence, one supposes, the gold medal they were awarded.

Arrogance is sometimes justified; it isn't always a bad thing to say, "I can ride that wild bull through a china shop," if you can pull that feat off when most of us cannot but it's still arrogance.

Reaching stick shaker obviously demonstrate that the AOA wasn't controlled in a way to enhance the glide performance. Since the AP was following the ILS the AOA didn't stop increasing, very far from best glide. Retracting flaps doesn't lead to AOA reduction (on the contrary if you wish to maintain a constant path), it only improve drag.

If there were some way the BA038 crew could have been alerted to the magnitude of the problem early on, SFLY's theories might have mitigated the outcome. Unfortunately the onset of the problem was subtle and probably not recognized for 15-30 seconds - there is that long a time constant in the response of a 250 tonne aircraft.

The real world sometimes won't behave like the book. :uhoh:

Don't feed the numpties and they will eventualy go away. I don't know about the rest of you but SFLY is on my ignore list as of now.

Having different points of view isn't an issue. I find interesting to notice that in both scenarios crews took manual control of the aircraft when no energy was left to prevent a high Vz fall. fortunately for the BA crew enough height was available to reduce this Vz prior to the impact. Understanding the mechanisms that delayed the manual override is very important since it is precisely what led both aircraft to enter a somehow uncontrolled* high Vz descent close to the ground.
*which is precisely why I don't understand how this could be an heroic issue in one case and a fault in the other...

So S.F.L.Y., please tell us what you would have done so we can benefit from your superior knowledge!

It's not that I'd have done better, I might have done the same, but since it's far from being optimum I'm interested to know why I would have adopted an underperforming strategy.

This was already discussed in the other thread, if you consider Vref close to best glide speed, variations will deteriorate the performances. Since the AP was constantly increasing the AOA to maintain a wrong path, gliding performances were constantly reduced until reaching their minimum (stick shaker). By reaching the stick shaker they basically reached the worse gliding performances they could achieve below Vref...

I think it's almost a case of "programming" - we are most use to what is "normal" and, even with the most prepared pilot, you have to add the "factor of disbelief". Part of the programming is not to go low on the approach! The first step in solving any problem is the acquisition of the correct information. Pilots have to make their decisions in real time. This crew was faced with an extremely rare situation - you might expect one engine to fail on final approach but not both at the same time.

[sorry, I know "don't feed" etc., but...]

This is plain wrong. BA038 started to have problems (one engine) at 720ft, lost thrust on both at about 600, and realised they had a dual engine failure at 480ft. They then started trying to get engines back. AP stayed in until below 200ft, stick shaker below that.

The other crew had warnings of problems at "high altitude" (see report), thrust retarded at 2000ft, unnoticed (it appears) until stick shaker at 460ft.

So, which crew had more height to recover with (460 or <200) ?
Which crew also had thrust to recover with ?
...and which crew managed to get the plane down on the grass such that some pax didn't even realise they'd crashed ?


BA crew didn't "fortunately" have "enough height" - they had less (at stick shaker) than the THY crew, and no engines. They simply flew a lot better with what they had.

The best one ever!
 

I was doing my post-flight paperwork when I noticed a young man stood there on the ramp peering intently at me through the little document hatch, so that I asked him if I could help him with something.

"That was a very bad landing!" said he.

Well, it had been the FO's landing anyway but it had been perfectly normal, one of those firm ones we are told to do nowadays so that the WOW switches tell the spoilers to come out and the engines to go to ground idle, tell the brakes to start working, all those minor details that go to make up a roll-out from a firm landing instead of an over-run into the bushes from a soft one.

"You must be new here," I replied.

"Why is that?"

"If you had flown with me much you would know that when I really make a bad landing I break the lightbulbs in the airport café!"

After a long silence he replied, "I still think it was a bad landing you made."

"Yes, and is there anything else I can help you with today? No?" I turned back to my paperwork and when I looked again he was gone.

It was lucky for him that I am so snobby and indifferent to opinions such as his; if I had really cared then I probably would have said, "Come a bit closer to the little window; I am hard of hearing," and then stuck two fingers in his eyes in the manner of Moe from "The Three Stooges."

The difference with THY and BA038 is that the Turkish crew was in a stall regime while the BA crew landed it "softly" into the ground. You make much more out of it if you try a normal landing outside a runway than if you stall the plane. That's why the outcome of BA038 was so much better.

To the benefit of the THY crew one has to admit that the 737 has less low speed protections than the 777.

Dani

Yep, good one.

Wx was < 1200' at destination, no CatII (this was 35 years ago), hand-flew the '9 down to about 200', nothing seen and returned to the departure airport - had one passenger tell us as he was getting off that "we just went up and flew around a while to keep everybody happy" before returning.

There's a million stories and everyone's an expert until they're called upon to perform.

FWIW, I think everyone seriously considering this question should read PBL's contribution very carefully before launching.

PJ2

BA038 Well. From Google I saw no evidence of a tail plant, all I saw as evidence of its arrival were two trenches caused by the main landing gear settling into the turf. These parallel "trenches" seem rather 'normal' for most of a quarter mile, at which point the right main dug in, failed, and was followed by the left gear. Slewing to the right, the a/c settled onto its engines, turned further right, then stopped. Like the Umpire says, "SAFE". But for the "short" all is well. As critical and sarcastic as I like to be, I have nothing but admiration for the Crew, in all respects. Wait, isn't this the Turkish thread?

bear

Dani made an excellent remark, the Turkish aircraft stalled while BA038 recovered while in both cases manual override was initiated in similar conditions. According to the report following AP override the 737 attitude went 8 degrees below horizon before increasing to 22 above horizon. This probably results from the combination of a full nose up trim with application of max thrust which momentum couldn't be stopped by pitch inputs (similar as for the Perpignan A320 accident).

The remark about the low speed protections is very relevant as the 777 and the737 were certainly not trimmed the same way when crews took manual control. While the 777 could be recovered after stick shaker activation, the 737 entered pitch oscillations and stalled as full power was set.

Do you seriously think that swapping crews between these 2 aircrafts would have changed the outcome once stick shaker was reached??

Wingview Got It Right
 

Wingview got it right when he said:
That's right they didn't even notice. :ugh:


As for S.F.L.Y., I suggest we all just ignore him.

Quote:-
"Do you seriously think that swapping crews between these 2 aircrafts would have changed the outcome once stick shaker was reached?? "

I think you are missing the point.

The crew of BA038 would have noticed the airspeed decaying below 'Vref' and taken remedial action before stickshaker activation.

The THY crew managed to crash a perfectly airworthy aircraft. The BA crew were performing their best efforts in a 777 without engines. They did so admireably well.
Big difference. No comparing the two.

In that case why didn't they take remedial action before stickshaker activation in their own 777?

I'm not saying the Turkish crew hadn't a serious lack of monitoring, I'm saying that both aircraft (for different reasons) reached stick shaker at low levels. At that particular point, swapping crews wouldn't have changed much of the outcomes.

A lot of people to mention BA's crew did so admirably well, but no one to elaborate on what they have done better that any other crew. I think most crews would have done the same (disengaging AP at stick shaker and flare what can be flared...). What could non-heroes have done different from that?