BOAC,
"Out of interest, why is the report published with deletions etc still showing?"

Am I mistaken or are you referring to the "comments" section?

I guess it can be rather interesting and even important WHO commented on WHAT and thus WHY the draft version has been changed, that can even be important, are we talking just about a common translation error correction or could some lobby have been involved?

Yes - the 'Remarks' section. It is unusual in my experience to have a released report with all the amended/deleted text left in place. It is however interesting to see the way changes were called and it is possible the depiction was chosen to deliberately display differences? The way it is presented has all the appearance of a draft.

Well, it was a draft which was commented on, and I guess that this will be a great help to historians studying the evolution of crash report, and gives the student of this crash quite some insight the evolution of this report. Makes it a sort of transparant report, it reports on itself.

I may well be mistaken, but I had the feeling that this might have something to do with lawsuits, in some way or another...

Aviate, navigate, communicate.

Three pilots in the cockpit somehow could not manage the first of these; and what will you wager that THY mgmt is focusing more on RA maintenance than on airmanship.

From another thread -

Article published in a UK magazine. Relevant to the subject of the opening post on the Kenya Airlines B737-800 crash.



Once known as ‘George’ the autopilot has come a long way since the first one flew in 1912. But has an over-reliance on automatic systems degraded many pilots’ basic handling skills? .

. The Jeppesen ILS approach chart was for Noumea Runway 11, New Caledonia, ICAO designation NWWW. The MSA to the north-east is 7000 ft and to the south 5500 ft. An NDB, callsign NW, is on the extended centerline 8 miles from touchdown along with another NDB and VOR at the airfield. Following the recommended procedures published in the Boeing flight crew training manual, the crew made full use of the automatic pilot systems. As the aircraft turned to final approach a fault occurred with the No 1 engine thrust lever clutch motor. Thus, when the automatics commanded a thrust increase to maintain a set airspeed, the throttle lever of that engine would not move from the last setting prior to actuation of the fault. The last setting was throttles closed idle thrust. Manual throttle operation was not affected.



The autopilot was programmed to descend the aircraft to 1800 ft until intercepting the glide path. The captain called for the flaps to be extended to slow the aircraft to approach speed and the first officer set the correct speed for the flap setting into the autothrottle mode control panel. As drag from the landing gear and flap extension took effect the autothrottle system increased power to maintain the demanded airspeed but because of the autothrottle defect only one throttle moved to increase power.

With a large split between the throttles, the autopilot tried to compensate by using a combination of aileron and spoiler controls to maintain directional control. At this point both pilots were concentrating solely on monitoring the autopilot mode status, unaware of the asymmetric thrust and the steadily increasing control wheel angle. The landing check list was being read when the automatic pilot suddenly disconnected accompanied by the aural disconnect warning. Unconstrained by the autopilot, the aircraft rolled rapidly beyond 45 degrees, and losing height below the glide slope. By now the GPWS below glide-slope warning sounded and it was then for the first time the crew saw the marked difference between the throttle settings.

Observing the No 1 (left) throttle was against the idle stop and wrongly assuming the engine had flamed out, the captain called for the engine failure and shut down checklist. The first officer hurriedly reached down to locate the Quick Reference Handbook (QRH). Still scrabbling to find the right page, he never saw his attitude direction indicator (ADI) hard over beyond 60 degrees of bank and the altimeter winding down in a blur. In real life, a searching helicopter would have located wreckage at a position five miles from the airport and a quarter of a mile to the north of the ILS inbound track. There would have been no survivors. At the time of estimated impact the simulator made a loud graunching noise and the windscreen turned red with simulated blood (a macabre modification by the technicians to the windscreen view to signify Heaven’s open door. So great was the impact, a re-boot of the simulator was necessary.
Modern airliners are equipped with superbly reliable automatic flight control and navigation systems. And certainly the remarkable reduction in CFIT over the years, attest to this. Yet there is a downside. One sage pilot described this perfectly when he said that automation robs situational awareness through absence of physical/sensory cues of flying the machine and as a result atrophies flying and thinking skills. He added that when automation degrades it can overwhelm even a highly competent well-trained crew. Other than that, automation used as intended - and not as an aircraft babysitter - was a tool for accuracy, predictability and timeliness of action.

Automatic throttle control systems have featured in several fatal crashes. In 1992, a China Airlines Boeing 737-300 crashed 15 miles from its destination. During the visual approach, with the autopilot and autothrottle engaged, the left thrust lever advanced while the right one remained at the idle position. The crew apparently failed to notice this asymmetrical power condition and allowed the aircraft to roll into a spiral dive.

Three years later in 1995, an Airbus A310 crashed in a steep nose-down attitude three minutes after take off. According to the accident report, the crash apparently resulted from a malfunction in the aircraft’s autothrottle system when power was reduced from takeoff to climb thrust. Mechanical jamming of the right throttle resulted in this engine remaining at full-power setting, causing an asymmetrical thrust condition that led to loss of control. The crew was slow to recognize the malfunction, which occurred over a period of about 40 seconds beginning when the aircraft had reached 2000 ft and continuing after it was cleared by ATC for a left turn. During this turn, the left bank steepened, with the Airbus over-banking into an 80 degree spiral dive and 290 knots before impact. Recommendations issued by the French Director General of Aviation in the wake of this accident, included the careful monitoring of throttle behaviour when the autothrottle is engaged, and its immediate disconnection and reversion to manual control if a malfunction occurs. Of course that was only saying the bleeding obvious, but crashes due to crew mishandling still occur.

In 1998 another Airbus crashed. This time at Taiwan, during a go-around from a high approach. Instead of disconnecting the autopilot when it was apparent that it was not coping quickly enough with thrust changes, the crew persisted with autopilot operation only to stall the aircraft due to an excessive out of trim situation, killing all aboard. Four years earlier an almost identical crash had occurred at Nagoya, Japan where investigators determined an extreme out of trim condition caused the aircraft to pitch up uncontrollably until it stalled.

In 1985, a China Air Boeing 747 flying at 41,000 feet over the Pacific in cloud and in moderate turbulence, experienced an autothrottle defect that caused one throttle to stay at idle thrust. Initially, there was no action taken to turn off the autothrottle system and adjust the power manually. In spite of having several minutes to act, the pilot failed to control the yawing moment and the 747 rolled inverted into a spiral dive. It reached Mach 1.0 and 5g, losing 30,000 feet before recovery was made below cloud at 9000 feet. .

Fast forward to 2009 where a Flight International headline reported Thomsonfly stall pinned on autothrottle.. No one was hurt when in September 2007 the Boeing 737-300 came close to stalling during a night ILS approach to Bournemouth airport, UK. The autopilot and autothrottle had been engaged at the start of the approach. However, an undetected malfunction caused both thrust levers to stay closed instead of holding approach power with flaps down. The crew did not notice the subsequent loss in airspeed as the autopilot tried to hold the ILS glide slope. The captain conducted a belated go-around with the aircraft reaching a pitch attitude of 33 degrees and speed of 82 knots before he was able to get the situation under control.

Not so fortunate, was Turkish Airlines Boeing 737-800 Flight 1951 that crashed in February 2009 during an ILS approach to Amsterdam. A defective radio altimeter fed wrong information to the autothrottle system causing the throttles to close to idle thrust. Like the Bournemouth incident, the autopilot tried to maintain the ILS glide slope by pitching up and trimming back. For over a minute the crew noticed the throttles were closed yet apparently failed to take corrective action until too late to prevent the aircraft stalling into a field, killing several passengers and crew members.

In most of the cases mentioned, prompt action by the crew to notice the worsening situation followed by immediate action to disconnect the automatic pilot system and fly the aircraft manually, may well have prevented each accident. As one pilot warned “Do you control the automated cockpit or does it dominate you?” While aircraft manufacturers encourage full use of automation, it is surely with the unspoken caveat that if automation is distracting your flight operation, early intervention should prevent things from getting out of hand. The Boeing 737 flight crew training manual covers this by recommending reduction of the level of automation as far as manual flight, to ensure proper control of the aircraft is maintained.

That last paragraph,” reducing the level of automation as far as manual flight” reveals the importance placed by manufacturers - and indeed airline operators, on the flight safety value of auto flight systems. Yet, the countervailing argument that manual flight skills are just as essential as automation is rarely mentioned in official manuals.

Perhaps a similar misguided philosophy led to the death of all 112 on board when an Adam Air Boeing 737-400 crashed into the Makassas Straits off Selawisi Island, Indonesia. The accident summary said the cause of the accident was failure of the pilots to monitor their flight instruments while trouble-shooting the navigation system. While in cloud, the automatic pilot disconnected as the crew were engaged in discussion of an apparent defect in the inertial navigation system. Unnoticed by either pilot, the 737 gradually entered a steep spiral dive. When the penny dropped, and the captain realized his aircraft was rapidly getting out of control, he made matters worse by pulling back hard on the control column instead of using the correct procedure for recovery from an unusual attitude. The aircraft broke up in the air.

We need a happy ending for a change, so you are invited to contrast the actions of the ill-fated Adam Air crew with those of a Mystere 20 Falcon crew faced with an unexpected runaway stabilizer electric trim on short final to runway 16 at Sydney, NSW, Australia. This is an edited extract from the Bureau of Air Safety Investigation of the incident. Keep in mind, the aircraft was flying over built up areas immediately surrounding the airport because this report will make your hair stand on end. The captain had 14,100 flying hours experience while the copilot had 8000 hours.

Following a normal flight the aircraft was established on final approach for landing. At about 140 feet above the ground, the approach angle flattened and the nose pitched up. The co-pilot, who was flying the aircraft, believed that a wind-shear situation had been encountered, and he initiated a go-around. As full power was applied the nose pitched up violently. The crew did not observe any cockpit indications as to the reason for this reaction.

The pilot in command took control of the aircraft and initiated a rolling turn. This had the effect of reducing the pitch angle, and by manipulating power levers and rolling, the pilot was able to regain control of the aircraft at about 6500 feet. A safe landing was subsequently carried out. Witnesses later reported that they observed the aircraft had reached pitch and bank angles of 60 and 40 degrees respectively. Because there had been no indication of the cause of the initial pitch up, the crew had difficulty in determining the appropriate course of action. Although the investigation revealed the initiating factor was probably a full nose-up trim situation, the crew believed the problem was caused by a structural failure or a thrust reverser malfunction

This brief official description of the incident did not tell the full story, however. In his report, the pilot stated (edited for brevity): At 140 feet above runway 16 the copilot stated that things were wrong and he was going around. Power was applied and loss of pitch control followed immediately. I took over control of the aircraft and I can still recall the IAS drop below 107 knots. I had both hands holding the control column fully forward trying to limit the rearing of the body angle. My concern was that we were going over on our back which would have been the end, as this manoeuvre started at about 80-90 feet AGL. In my mind was that the vertical lift of the aircraft had to be minimized so I rolled it to the left in a very steep turn and had the copilot close the throttles to assist me in getting the nose of the aircraft to come below the horizon. This turned out to be successful and we recovered prior to ground contact. As power was restored the nose pitch attitude reached again the 60 to 80 degrees (as some witnesses in the control tower claimed)

During the first go-around the flaps and gear were retracted and we did a series of the above manoeuvres, using roll and power off and an application technique as described above, each time gaining some height above ground level although we had very limited heading control. We did this for about 5 or 6 times and obtained about 6500 feet AMSL During this time I was unable to take either hand off the control column or relax the force required to limit the rear of the body angle. The copilot was completely occupied with the closing and opening of the throttles to help me semi-control the nose position. The aircraft eventually flew out of the problem and returned to normal operation with no further input from the crew.

Once the first recovery had been achieved I knew that I could control the aircraft to a certain extent whilst the fuel lasted. This could not have been possible without the excellent crew co-ordination between PF and PNF. A help to me was the knowledge of aerodynamics instilled by instructors during my early training on Tiger Moths.

During the technical investigation of the incident no fault could be found in the stabilizer actuator although another fault which was considered responsible may have been intermittent in nature. The captain of the Mystere Falcon exhibited superb airmanship in recovering the aircraft from a deadly situation and if a military pilot would no doubt have been recommended for the award of the Air Force Cross. This was pure flying skill at its best.

But all that happened many years ago. The game has changed since then, and now we have the situation almost world-wide where low cost airlines recruit low experience pilots as second in command of large airliners. While this may be partly due to a perceived shortage of experienced pilots, it is more likely aimed at cost-cutting where pilots are willing to pay for their own training on passenger jets. It is common to see newly graduated commercial pilots self funding a type rating on a Boeing or Airbus. Next thing is to find an airline happy to offer them a first officer position. No problem there, with agencies keen to place them (at a price, of course) with an airline willing to hire them in the right hand seat for six months. Captains are expected to look after the new boy or girl by giving them take off’s and landings in fair weather as the youngsters build up their jet hours to qualify for full-time jobs.

Because of the low experience of many new first officers, it is with some relief their mentors can plug in the automatics from take off to landing and sit back and relax while the first officer merely monitors the automatic pilot on his leg. With airline policy dictating the full use of automatics during revenue flying the exposure to the real world of manual flying for skill retention, is neatly side-stepped.

In this article we have read of fatal accidents caused by crew mis-handling the automatic systems – particularly while flying at night or in IMC. Statistics reveal Loss of Control as the new major cause of aircraft fatal accidents. This was highlighted during a recent Asia Pacific Airline Training Symposium held in Hong Kong where the Airbus representative urged the aviation industry to confront the issue of how to ensure long-haul pilots maintain basic flying skills in the face of ever-increasing aircraft reliability and cockpit automation. “I think that at a certain point in time we need to bring back a little bit of handling”. He advocated more simulator time for pilots to hone their basic skills. “We put people into our training today who have forgotten how to fly, basically” That would surely be the understatement of the year.
Of course not all pilots have forgotten how to fly. But consider this true story of a 2000 hour newly recruited first officer at the controls (on automatics, of course!) of a Boeing 737. With the airport in sight at 15 miles, the captain suggested it would be a good opportunity for his Number One to disconnect the automatics and fly by hand. This perfectly reasonable suggestion was met with a shocked look and shaking of the tousled head as the first officer said no way was she going to hand-fly when the automatics did a better job – passenger comfort and all that jazz. Now it was the captain’s turn for the shocked look and shaking of head. Another time, a keen first officer asked his captain if he (the first officer) could turn off his flight director during a VMC climb so he could practice raw data manual flying. The captain refused; saying, leave that to the simulator.

While some of the more enlightened operators permit manual flying in appropriate airspace and weather conditions, others discourage it. A regional operator in Australia flying turbo-prop commuter aircraft insists crews use full automation from after lift-off to short final even in CAVOK conditions, leading to the ridiculous situation where furious knob twiddling of the autopilot takes place as the aircraft tracks from downwind to base and final in the circuit area. These are the same crews that eventually move up the food chain to fly the big jets. The regulator doesn’t mind one bit as long as rules are not broken. .

The reality is that manufacturers and airline operators will not venture from their comfort zone and encourage pilots to hand fly at their discretion. Some captains will quietly encourage a spot of manual flying here and there – flight directors on, of course. No point in stretching the friendship too far, they say. One captain interviewed observed that automation complacency is so well entrenched that many pilots politely decline his suggestion they hand fly on raw data occasionally –even if a recurrent simulator session is getting close. A few months ago, a Boeing Company check pilot talked to pilots of a major Hong Kong-based airline. In his travels, he noted that some airline pilots tended to avoid the opportunity to practice hand flying skills until the very last minute before a simulator session. This was a waste of time, he said – because manual flying skills had to be maintained throughout the year and that a hand flown ILS in good weather after months on autopilots, did nothing for basic flying skills.

Following the UK report on the near stall of the Thomsonfly Boeing 737-300 mentioned earlier, Flight International quoted a CAA observation that: Pilots familiar with operating older aircraft, which had more variable reliability, are nearing the end of their careers, and there is a generation of pilots whose only experience is of operating aircraft with highly reliable automated systems.” The writer maintained that exercises mandated in recurrent training programmes have scarcely changed since the days of the Super Constellation. So training no longer represents what crews are likely to have to deal with today.

The solution is change the mind-set of regulators and operations departments. While Loss of Control accidents will never be eradicated, training departments should learn the lessons of past accidents and apply them to more realistic simulator training. Normally in recurrent simulator training, each crew member can expect two hours per session as pilot flying. Over a 12 month period this amounts to at least eight hours of handling per year depending on the number of sessions scheduled. Most of these sessions in the simulator will be on automatic pilot, with occasional manual flying to meet regulatory requirements. One engine inoperative flying forms a good proportion of each simulator session and much of that is on automatic pilot. This does not leave much time for practicing raw data pure flying skills. That policy must change if airlines are serious about learning the hard earned lessons from past accidents.

While LOFT exercises are valuable for practicing CRM skills, they rarely provide manual handling practice. Valuable simulator time is sometimes wasted in lengthy LOFT scenarios that require complex checklist use and associated crew discussion. Often the pilot finds he has done only two landings by the end of the session. To ensure a high standard of manual flying skills are maintained throughout the year (not an unreasonable expectation), simulator sessions should be scheduled to allow equal time between automatics and raw data manual flying. If that is a problem then additional time should be scheduled. Simulator training might be expensive but peanuts compared to the cost of a crash such as those described above.

Pilots should be given the opportunity to practice raw data hand flying in sequences covering high and very low altitude stall recovery, circuits and landings in strong crosswinds, unusual attitude recoveries, GPWS pull up manoeuvres, bad weather low level circuits, forced landings following loss of both engines, flight on standby flight instruments, instrument approaches general and all flaps up landings on limiting length runways. Additional sequences could include black-hole approaches over terrain devoid of ground lighting, and slippery runway short field landings. For the purpose of all these exercises, the automatic pilot, autothrottle and flight directors should be left off. To keep these pure flying sessions within reasonable time limits, the instructor should use the freeze and re-positioning facility of the simulator as well as common-sense reduction of QRH and checklist reading. Keep in mind the aim is to allow the pilot the opportunity to practice basic handling skills within the time constraints of simulator scheduling.

Earlier, mention was made of the superb skill and airmanship displayed by the captain of the Mystere 20 Falcon at Sydney, in recovering from a series of extreme attitudes caused by a stabilizer trim malfunction. He attributed this skill to lessons instilled into him by his instructors on Tiger Moths. Who knows that one day in the future, a pilot recovering from a one in a million jet upset in a highly automated airliner will thank his simulator instructor for teaching him the art of pure flying.

Good article and worth both the bandwidth and the read. It will, however, be mostly foreign or old-fashioned to many operations managers and perhaps some younger pilots who have never flown manually, (MPLs, who can't even legally rent a C-150).

Many here have foreseen what is now occuring: Accidents resulting from inexperience and/or lack of thorough training and systems knowledge and not from mechanical/navigation/ATC or weather causes. Such views seem to be somehow justified by the impression that automation means the airplane can "decide" as opposed to merely performing highly accurate flight. Automation is absolutely by far a safer system but it requires engagement of the crew to work.

Oakape : excellent article, well worth the time to read it . Thanks for posting it.
But isn't it ironinc that , back to the TK AMS report, that it was the less experienced FO that applied the correct basic flying skill procedure when approaching the stall (at stick shaker) , and it is the more experience Capt/instructor that , by taking over, sealed the issue ?

[QUOTE]and what will you wager that THY mgmt is focusing more on RA maintenance than on airmanship/QUOTE]

I think you are missing the point. Aviation is a team game and each member of the team needs to be on top of his game i.e. professional

Better airmanship MAY have avoided this accident but a serviceable RA WOULD have avoided this accident.

I would hope all affected parties are doing all they can to ensure it doesn't happen again.

You would think that the airlines would try and hire the most experienced pilots available. The answer is not so. Beancounters rule.
If you look at the recruitment at major low cost airlines they take very inerperienced pilots who can just barely handfly, but can operate the automation. These pilots get upgraded to Captain/training positions.
This has resulted in a generation of captains who write the manuals/sops that encourage the use of automation and ban handflying.
I know of many unemployed pilots age 50 and older with 10000+hrs unable to get a job due to the cost cutting of many airlines.
Hiring these pilots would cut down the handling type of accident. Most have flown in aircraft not as reliable as the modern jets and have superior handling skills and most important are not complacent.
Automatic flight controls are great when working but a killer when they malfunction. It could be said that some autoflight systems are far too complicated in relation to failure modes,some of which are not even known about until an incident/crash.
Crews must be able to disconnect everything and handfly just like the days of the DC-3. Hand flying is a skill learned through practise not by watching the autopilot.

The report also notes that the THY capt., who took over the recovery and then failed to move the throttles, had not had approach-to-stall training for a considerable time. The FO was effectively better trained and qualified to handle the recovery - and the evidence is that he was doing so correctly.

It is maybe more ironic when you compare with BA38 who were in a similar situation but without the benefit of working engines. Capt. Burkill left the PF flying and focused on problem solving and took one action (flaps) which proved to be decisive, yet he was roundly criticised for it in some quarters, including here, with allegations that he did nothing or "froze".

This crash (IMO) is a textbook example of why Pete Burkill did exactly the right thing by not taking control.


Also, where before I'd be agreeing with "the crew messed up", I'm now starting to feel sorry for the FO. He's on a training flight with two senior guys watching him, he's got a problem with the plane that he doesn't fully understand (causing issues setting AP etc.), he's been put on a tight approach forcing a glide slope intercept from above, and ending up (maybe inevitably) unstable. He doesn't have the authority (THY SOP) to call the go around, and the capt. won't (for whatever reason), so he's stuck with the unstable approach. Then all threee crew miss the speed decay, the FO gets stick shaker, reacts correctly, but the **** captain takes control off him and crashes the plane.

So the SOP is the ultimate authority now?
 

I think common sense should have prevailed, not blind obedience to the SOPs.

The FO's (or any other pilot's) ultimate goal should have been to fly/land the plane safely. If an SOP risks bringing you into a dangerous situation I don't think it would be wise to adhere to it!

Sealed / Secure Cockpit Doors on THY 737
 

I haven't read the report, but am just wondering if there is any reference to the problem whereby the pilots were trapped inside the cockpit due to the inability of the emergency services to gain access through the secure cockpit door

In a word, No, or at least not that I can find.

The report is light on survivability, although as Appendix E states this is an ideal study case as evidence was not destroyed by fire.

It appears from what Appendix E says, that separate survivability study(s) may be being undertaken - which would explain the low level of info in the report.

Looking at the crash damage and the injury / fatality distribution that is in the report, my feeling is that anyone in the cockpit experienced the highest g forces and was extremely unlikely to survive, whether promptly reached or not. Any "problem" with the secure cockpit door would appear to still have the status of rumour rather than confirmed fact.

- you need to remember two things:-
1) The F/O with Peter was pretty (more?) experienced on type I recall
2) The F/O with THY was under training - making a totally different decision process for a training captain.

At long last we now have a detailed account of how it happened. If we are asked to explain to laymen who will need to have a very simple and short answer then all I think I can say is pilot error. However the interesting aspect of the report is to be found in Appendix B , the respones of the interested parties. This is where the future battle ground lies, where ATC says there was nothing unusual about a short intercept above the glide, THY says the crew did it all by the book and they did not need to know about rad-alt glitches and the manufacturers say the crew should have known better how to engage the AFS.
I am of the opinion that the Dutch have acted admirably in publishing the full text of these so called responses. No one can now blame them of any undue influence.
The part I think is best descriptive of the whole sad affair is the THY response :

“At Turkish Airlines, the automatic flight system is used as much as possible.”
“to reduce workload, enhance flight safety, situational awareness and fuel economy” should

be added to the end of this sentence to avoid any negative connotations

There seems to be a increase in the trend of air accidents involving automation, which raises questions as to the validity of the claim of enhancing flight safety through reduction of work load. It therefore raises the question whether the another gain in automation is more cost savings through increase in what otherwise would be a reduction in crew duty hours. The old saying is hard work never killed anybody. For situational awareness see the MD83 ATLAS JET Isparta crash.

The FO was an ex-air force guy.

Given the Captain's age, and flight hours, he was 99% likely to be an ex air force guy as well.

Now, you don't touch to the controls when your senior take over the contols, period.

That's why he couldn't itervene. His hands were tied.

This isn't the first ocurance of a this kind of accident in TK's history, and it won't be the last.

Safety Concerns:

I am very disturbed by this statement. Wasn't #2 RA operating? Two ASI's were operating. Weren't manual thrust levers still available? The failure of one RA is a mere irritant, and the THY culture regarded it as such by their failure to snag it on previous flights.

CRM or no, how did THREE aviators fail to aviate? Let's not allow the spotlight to wander from its proper focus. :rolleyes:

The whole flying thing is teamwork. Concentrating solely on airmanship will never eliminate all accidents because humans are fallible. With the best will and training in the world humans will still continue to make errors.

That is not a statement saying ignore airmanship issues but it is a statement saying that you ignore other clear indicators at your peril.

And yes I cannot understand any pilot who ignores any defect with a radio altimeter system which only interacts with other systems below 2,500 feet. i.e. very close to the ground and during a critical phase of flight.

This unfortunate accident as with Spanair is not just about airmanship. There are other significant factors.

The failure of one radio altimeter is not a mere irritant as the consequences can be enormous hence an MEL procedure which de-activates a faulty system. Contributing to this accident was the fact that the system should have been de-activated prior to that fateful flight.

We can never eliminate all mistakes but we all have a duty to maintain the highest levels of professionalism. That includes the logging of defect which we all know isn't just a Turkish airlines culture.

Please do not let undue emphasis be given to "intercepting the G/S from above." In years gone by this was not uncommon. Agreed ATC should not do it; usually it is LOC & G/S together. Some airfields were expert at that, whilst asking for min clean as well. Interesting if medium length finals. If ATC was going to give an above interept, and I was based at AMS for many years, they should ask first if you ready and able to accept a shortened turn in. On an EFIS a/c there is so much information to agree/disagree such an offer. When self-positioning to expedite an arrival it was quite common to turn in and intercept G/S at OM. It took good judgement, and the A/P could be used to good effect if necessary. Manually was no big deal either; depended if you were VMC or not.
In doing so, intercepting from above, it heightened your situational awareness and made you MORE alert, not less. This is the mystery to me. I've not yet read the report and wonder if the CVR gives us a clue.
What will be interesting to see, considering this, and the Buffalo crash, is the response of the authorities and airlines to manual flying skills and tests. I know of airlines, where due to their large number of sectors each month, the general expectation of our colleagues is that those pilots must be skilled in manual handling, short rwys, numerous circlings, NPA's and visual circuits. Due to the emphasis and encouragement of using automatics, and an active discouragement of visual approaches, the opposite is true. "Use of automtics make for a safer opertaion". They even get nervous landing on Rwys with no G/S references. What ever happended to basic parameters and Mk.1 eyeball?
I still say that the pilots are the last insurance policy for the company & pax. Use of the automatics for all reasons stated, safety, fuel, comfort, is fine. The insurance is needed when they muck up. If they, the crew, are not fit for purpose when needed then something sure ain't right; even worse if it is the mis-handling of those safety enhancing automatics that started the cataclysmic chain of events.

To ME it's really simple. Up, under or level picking up the GS, THY SOP is to be estabished at 1000ft. They weren't but if they were, they had 2 spooled up engines and the possibility to get out off the stall without any problem. The report says nothing about the consequences of not being established. If the report would have mentioned this, THY management never could have said that they (crew) has done everything they could.
What also wanders me is that, according to the CVR, they went from flap 15 all the way to 40???
Other question. It seems that THY SOP is also to make Auto Land only?! Why and doesn't this maybe make you less alert because of this?

What's that all about?

The crew goofed up the approach.

Sorry to say, but it's that simple.

CptCaveman,

Your location says Istanbul, but you obviously don't know what you are talking about. :ugh:

The F/O was NOT an ex Air Force guy. He was a new hire, still in training.
The other 2 pilots (Captain and the Line Check Airman) were ex Air Force pilots. One was an F16, the other F4 pilot with great reputation for safety.

The message I get from this accident is; If this can happen to those experienced pilots, it can happen to me. So I should NOT spread rumors, look only at the FACTS, and decide for myself how to avoid a similar situation.

Referring to those of you sit behind your keyboards, and type how they screwed up should think carefully before typing...

Very frustrating to see "fellow" pilots posting messages here, acting like ambulance chasing lawyers or newspaper reporters with absolutely nothing to do with aviation.
This thread, Air France thread, all the same..

Am I the only one who feels this way???:(

767Capt

Perhaps the issue is distraction.

There were two or more simultaneous missions underway; the FIRST should have been flying the sector safely. The line check was secondary, and the #1 RA threw more distraction into the cockpit, probably compounded by the extra crew.

The FACTS are - whatever the background and flying record of the crewmen, and whatever the autothrottle problem (including RA), allowing T/L's to remain at idle for 100 seconds in approach configuration with energy rapidly decaying, simply tells me that nobody was minding the store.

767Capt;
If that's all you see then I submit that you're not reading either thread very thoroughly. Yes, there are a few comments which are pretty blunt and off the mark but there are many more thoughtful contributions from experienced aviators both here and on the AF447 thread. I see no "ambulance chasing" comments among those who fly nor do I see a brashness that ignores the fundamental fact that any one of us could have been that crew.

What I do see then is puzzlement and an earnest search for a reasonable, rational explanation for why three of our colleagues stalled their airplane when nobody, even the safety pilot who's job it was to notice such things precisely because the guys up front may indeed become inadvertently distracted by the training regime, noticed how far the speed had bled off.

How many of us have had a serious, unexpected incident? Have each one of us who do airline transport work not been there at some point in our careers and not made headlines but learned that we are not invincible?

As for those who make blunt comments, examine them and decide if that's just bluntness or is it something meaner? If so, don't read the poster's work anymore and turn to what you believe is from earnest professionals.

No, a serviceable RA may have just delayed this crew's accident to another day, another situation.

Radio Altimeters, ILS receivers, and IRUs, being part of a Cat III autioland system, are thoroughly analyzed for safety such that an annunciated failure is acceptable; an unannunciated failure is not acceptable. The RA is a simple sensor that outputs what it detects, and it does a fine job of that. It, however, is unable to detect the difference between a valid ground return and leakage between its antennas, due to corrosion or other factors. That falls into the area of Undetected Failures at a system level, a big no-no.

The autopilot and flight director computers receive inputs from both or all three radio altimeters, and compare to decide if there is a fault. The fail warn output of each sensor make it easy most of the time, and the 737 autothrottle computer looks no further, so does not compare values from RadAlts, but merely uses #1 until it puts out Fail Warn.

A pilot, who could see the #1 RadAlt error, could have disengaged the circuit breaker on the #1 RadAlt as soon as it occurred (high on the approach or before), and would have avoided misleading the A/T computer, the GPWS, the pilot during final approach, and probably other devices.

I don't care what your SOPs are with regards to disengaging CBs, I'm merely stating a fact. Too many of you don't remember the early days of EFIS and FMS, where resetting a Circuit Breaker was a usual means to reboot a wayward system.

GB

P2J,

I was referring to those "Blunt and off the mark"comments, specifically replying to Captcaveman who posted incorrect information regarding the flight crew.

God forbid if you , me or anyone else has to go through a similar situation, and after they die, "fellow pilots" posting incorrect information is disrespectful in my opinion. Especially if you personally knew any of these pilots as I did.

If you re-read my message, you'll see that I encouraged for us to look only at the facts, learn from their mistakes (only after the facts are known) and not post incorrect info.
That doesn't serve any purpose.

As for your suggestion that I should not read their post and only read posts from earnest professionals; I don't know who those people are. So I kind of have to read them all.

It would be better if all pay attention to what we post, again, these aviators ARE NO LONGER with us, and they have no way to explain what really took place.

Best.

767Capt;

Understand; we're on the same page...

best as well. PJ2

[QUOTE]No, a serviceable RA may have just delayed this crew's accident to another day, another situation [QUOTE]

Bit harsh. Humans are fallible not perfect. We have take off warning systems for example because crews do overlook the small issue of setting the flaps or ensuring all the doors are closed or whatever. Its not ideal but its human behaviour. It doesn't reflect on professionalism at all, it can happen to anyone and often does, you just get away with it because the holes in the cheese on that particular day didn't line up.

All we can do is try our best to ensure the holes in the cheese don't line up. In utopia we don't mistakes, here on earth we do. Knowing that to be an undisputable fact, why would you accept anything less than an aircraft that is serviceable or has all known defects under control by proper use of the MEL.

The accident report says two previous crews noticed the RA fault and decided not to log it. A third crew were unaware of the defect, lost situational awareness for whatever reason and paid for it with their lives.

I cannot tell where the crew were on the scale of professionalism because I wasn't there but just as in the Spanair tragedy, not dealing with a defect has costs lives. The holes in the cheese lined up.

Go on about airmanship as much as you want, even the best crews will one day have an off day. I hope when that day arrives all your onboard systems are working as advertised or have been deferred correctly.

767 captain : I do not quite follow your reasoning.

Captcaveman mentioned the fact that the F/O was ex-air force and you categorically said he was not and argue we should not denigrate the guys and pass incorrect info.
But in fact the Dutch report says page 9 :
Later in the report said he had 44h on type.
The Safety pilot is reported there to have 720h on type and was 28 years old.
The capt was repported to be 54 years old with nearly 11.000 h on type.

Are you saying that info is incorrect ?

I know also a bit Turkey, and the report info is correct, I am, for one encline to believe that in this combination, nobody in that cockpit was going to question the Capt taking over and actions thereafter.

@ Barit1

Quote: Perhaps the issue is distraction.

There were two or more simultaneous missions underway; the FIRST should have been flying the sector safely. The line check was secondary, and the #1 RA threw more distraction into the cockpit, probably compounded by the extra crew.

The FACTS are - whatever the background and flying record of the crewmen, and whatever the autothrottle problem (including RA), allowing T/L's to remain at idle for 100 seconds in approach configuration with energy rapidly decaying, simply tells me that nobody was minding the store. unquote

I'm sorry but I find your comment extremely...well for a loss of words...dumb

If you read the report you will find that notwithstanding the faulty retard mode the thrust would have been at idle anyways due to the fact that they were descending from above the glideslope and trying to decelarate at the same time. The thrust was only improperly at idle for about 25s after they reached FAS at about 700 feet. One of the reasons given that they didn't notice the autothrottle advancing and maintaining FAS was that they were probably distracted by performing the landing C/L.

Yes, they should have made a go around according to THY procedures and international established procedures, no question. I wonder though, how many on this board have dipped (just ever so slightly) below the stabilised approach criteria at any one time??? Be honest now!!!

Please read the report before commenting

Assuming that our industry has achieved the status of ‘a highly reliable (ultra-safe) system’, we should use alternative analyses of accidents to identify solutions.
Highly reliable systems are complex and lack predictability and thus may not respond to conventional methods of control – fixing safety problems.

Many posts, including those ‘blunt and off the mark’ comments use mechanistic thinking. This is based on ‘evidence’; it assumes that facts from one context applies in another (tech failures vs human failures), it assumes a linear relationship between cause and effect, and often results in statistical based solutions. Mix these together with weak understanding or failure / inability / reluctance to consider the human element, often results in biased viewpoints.

We must take wide ranging and alternative views. Consider the many contributions in this accident how they might link or interact with each other and modern flight operations. It is unlikely that we will be able to determine a precise outcome – neither the problems nor solutions, because the very nature of complexity prevents us from forecasting the result of safety activities.

By considering the contributing factors, links, and interactions, we can generate a framework for action – something to hang future safety improvements on. We might seek to improve / eliminate all of the contributions factors as no one issue can be proven to prevent future events, the analogy is adding cladding to the frame work and thereby strengthening the structure – safety.
However, this might be a weakness in thinking, often leading to a trade off between safety and economics – one or the other. This requires an alternative view – a culture where safety and economic prosperity is developed jointly.

A complementary and very important aspect is to reconsider the many assumptions associated with the contributing factors.
The manufacturing and regulatory processes make assumptions about equipment reliability and warning system effectiveness; operationally the industry holds many assumptions about human performance – pilot and ATC, context dependent.
The industry (top-down and bottom-up) should re-evaluate these assumptions; are they still valid, has the operating environment changed, are ‘old aircraft’ designs applicable to new pilot training, and is the pilot (human performance / capability) changing – adapting, or failing to adapt to a new operating environment (all the arms of the SHEL model).

Much of the above was influenced by Systems Thinking – “it enables people to see a bigger picture that makes more sense of their world”.
At least read the preface and summary; read them again in the context of aviation safety, and then again relating the issues to this accident.

“… difficulties are bounded problems, and individuals will know when they have found the solution. … with a mess there is rarely agreement about where the problem actually lies or where improvements can best be made, and they are subject to high levels of uncertainty.
Another difference between these classes of problem is that when the problem is a difficulty an individual claiming to have the solution is an asset, but when the problem is a mess that individual is usually a large part of the problem!”

Also see Revisiting safety and human factors paradigms to meet the safety challenges of ultra complex and safe systems.

flyburg:

My statement was certainly incomplete, and I'm sorry you find it dumb.

I think most human factors engineers would agree that the human animal doesn't do a great job of monitoring a closed-loop system (e.g. autothrottle), particularly in a busy/distracting environment. The transition from "above-GS" to GS capture is effectively a system mode change that the A/T and the crew both missed.

If the system design leaves the human out-of-loop, then mode changes should be automatically announced to recapture the pilot's attention to focus on monitoring.

But that doesn't excuse what happened. I see this accident bears a remarkable resemblance to DCA73AZ005, EAL401, where again no one was minding the store.

Hello Barit1,

My response was certainly worded harsly and reading your response maybe too harsly.

In regards to your last response, yes, humans are excellent performers but bad monitors. The report actually mentions this. It even makes a remark about AP annunciations and how most pilots ( all airlines to do not monitor them carefully)

Please read the report, I won't say this wouldn't happen to me. I you read carefully all the holes in the swiss cheese lined up perfectly that day. Next day they might not have. Your reference to EAL. Excellent, think of the Tenerife accident, just a small mistake, Taking off without clearance. Has happened many times (really) just this day,somebody happened to be on that runway.

Anyways, learn the lessons and apply them

ATC Weather,

It can be confusing to people that are not familiar to the THY system. I hope someone who works there can better explain than I, but I will try:

There were 3 pilots in the cockpit; 2 of them (Captain Hasan Tahsin Arisan and the Safety Pilot, F/O Murat Sezer) were former Air Force (one F16, the other F4) pilots, F/O in training was Olgay Özgür. He was NOT former Air Force or any branch of the military. (His father was a Retired Army pilot)

F/O Özgür was 29 years old and graduated from Ankara University- Geology dept in 2005, then got his Commercial Pilots license (#4554), worked for World Focus Airlines, then got hired by THY on 11 April 2006.

If you understand Turkish, here is the newspaper article about F/O Olgay Özgür:

Babası Emekli Karacı Pilot Albay olan Özgür, küçük yaşlardan itibaren havacıkla ilgiliydi. 29 yaşındaki Özgür, Ankara Üniversitesi Jeoloji Mühendisliği’ni 2005’te bitirdi.

29 yaşında 2. pilot

Üniversite eğitimi sırasında Ankara Esenboğa’da bulunan Sindel Havacılık’ta pilotaj eğitimine başladı. 2005’te 4554 numaralı Ticari Pilot Lisansını aldı. Olgay Özgür, ilk olarak Isparta’da 2007’de uçağı düşen World Focus Havayolları’nda göreve başladı. Burada MD83 tipi uçakta 450 saat uçuş gerçekleştirildi.

World Focus Havayolları’ndan sonra 11 Nisan 2006’da Türk Hava Yolları’na geçti. Boeing 737-400 ve 800 uçak tiplerinde eğitim gördü. Evli olan Özgür, THY’de kıdemli ikinci pilot olarak uçuyordu. İngilizce bilen İkinci Pilot Özgür’ün toplam uçuş saati 3 bindi.

Alf507h,

Thank you for the very informative and interesting post.

Digging a bit deeper, I found the following sentence very thought provoking in your link:
"In System Failure I argue that the dominant approach to policymaking was based on mechanistic and reductionist thinking."

C/L/R (or C/R/M) is one of my interest areas as well. It works. After the 1978 United Airlines accident, UAL started their industry leading C/L/R program to prevent another accident from happening ever again, and there has not been a single loss of life as a result of Pilot Error at United since!

You gave me something to research for the next couple hours.. (Wife is not too happy- on Mother's Day:))

Best.

Wait a minute. That's not what the official report says. It says the F/O in training was the 42 yr old ex air-force guy and the safety pilot was the 28 yr old guy. (ref: English report pages 9, 181 and 182) I think you might be confusing things. I can't read Turkish but I would never thrust any newspaper article over an official report in aviation matters. :=

Either you or the official report are making a mistake, and since the draft report has been reviewed by all parties involved, I tend to believe you are the one making the mistake.

Best regards,
Sabenaboy

767Capt ,I fully agree with Sabenaboy , I think you maight be confused by the newspaper articles ( I cannot read Turkish either, sorry ) as to who was the acting F/O PF and who was the safety pilot on this flight.

According the report , The F/O PF is the 42 years old one with 44h on type and 4000 h in the airforce that pushed the throttles forward after stick shaker activation, and the safety one on the jump seat was the 28 ( or 29) years old one.
On this configuration,when the Capt instructor took over, the 2 others were , in my opinion and knowing a bit Turkey very uniquely to question the Capt actions.
Correct me if I am wrong.

Capt. Caveman,
I would like to apologize to you for MY incorrect statement. I was wrong in stating that the F/O was not ex military, he was..
It was the Safety Pilot who was the younger pilot and was from civilian sources.
They carry 3 pilots, and I made the mistake of assuming the younger guy was the one sitting in the right seat.
My apologies again.

Sabena Boy and ATC Watcher,

I stand corrected, please see my apology post to Capt Caveman.

Thanks for correcting me.

BTW: do either of you have the link (English please) for the full final report?

Thanks.