Kegworth

[Old Fella]

CRM/MCC training.

It seems "Zorst" has some difficulty in accepting the usefulness of CRM or MCC training with his claim that no study has shown any benefit derived from such training. I cannot argue with his claim, but I certainly am sure that airlines are not going to spend funds on putting crew members through training courses which they cannot see as being worthwhile.

Having had many years as a Flight Engineer in both the Military and Civil environments I can tell you that I have personally experienced the benefits of CRM training. Whilst there may not have been any "study" to show a tangible benefit, and for that we only have the word of Zorst, many investigations into aircraft accidents have shown that had the PIC been willing to use his crew resources, or had not been a "one man band", the outcome would most likely have been different.

The best Captains with whom I flew were those who recognised that those occupying a crew seat had a contribution to make to the safe and efficient operation of any flight. Thankfully, most Captains these days have overcome any tendency to think of themselves as Gods.

[Tee Emm]

[quote]The Kegworth environment was doubly pressurised because the Captain took control from the FO (changing crew roles at a critical time) and disconnected the autopilot - dramatically increasing his own workload. ]

Disagree. Any pilot worth his wings should easily be able to handle an engine failure and hand fly at the same time. Happens all the time in single pilot light twins and they are a damned sight harder to fly on one engine than a jet.

RAF pilots flying Canberra bombers single pilot with no autopilot and in IMC at 45,000 ft handled this sort of situation through normal training and without the benefit of simulators. We didn't see Canberras falling out the sky with engine failures at altitude. It is all about good training. And if todays simulator training places accent on full use of automation then no wonder the automation brigade are so tied up in knots pushing buttons that they forget how to fly an aeroplane - a situation only about to get worse with low hour cadets in the RH seat of jet transports and brought up on a diet of automatics.

By disconnecting the automatics if he chooses, at least the captain can get an immediate feel of the flyability of the aircraft. In the 737 Classic the use of automatics on single engine is quite awkward requiring partial manual flying anyway (manual rudder and trim, no auto-throttle) while carefully "monitoring" the control wheel position in case the rudder is not kept in trim.

Having said that, there is a case for retaining use of the autopilot in such circumstances if the captain feels he is not confident or competent enough to hand fly his aircraft - but what a sad reflection on so called "progressive thinking" on the subject of automation versus pure flying skills. The old story about the pilot who admits he can't fly for nuts but that he can type at 80 words a minute is never so true as an example of todays pilots.

[OzExpat]

Just one question from a dumb colonial. Had the Kegsworth crew responded correctly, would airline safety have ever been improved? Put another way, would we have faced the same problem in a transition, for instance, from the B747-200 to the B747-800?

I'm pretty sure there's no answer to that question but I'll sit back and wait to be educated.

[lomapaseo]

Just one question from a dumb colonial. Had the Kegsworth crew responded correctly, would airline safety have ever been improved? Put another way, would we have faced the same problem in a transition, for instance, from the B747-200 to the B747-800?

I'm pretty sure there's no answer to that question but I'll sit back and wait to be educated.

Ha ..at least this part of the discussion looks forward rather than backwards in hindsight

from my study of crew perfomance with engine failures there were many similar muck ups both before and after Kegworth. With all the data plus post event crew interviews I formed the opinion that you can't blame the human for a reaction, but instead have to look at the experience base and training. When you look at those issues you begin to see all the precursors.

Examples: the crew expected engine failures to be overt (lots of noise, vibration, left foot right foot stuff)

The training probably didn't address at that time the deciphering of engine gages in a CRM atmosphere before grabbing a throttle.

Lots has changed since then to address the crew training issues

see also the engine training material on this page http://www.fromtheflightdeck.com/

[Tail-take-off]

Albertz

It has been a long time since I flew the 737 & my memory is getting a little blurred with time but as I recall the fire switch does not disconnect the Generator drive just de-energises the gen through the GCU. As for the Hydraulics it is not possible to physically disconnect the eng driven Hydraulic pump - the fire swich electrically de-activates it. (You would still have the Electric pump in any case). All of the above will be restored by returning the fire switch to normal position.

Of course what you can't do is suck the fire extinguisher agent back into the bottle if it has been discharged

[moggiee]

Originally Posted by Tee Emm

Disagree. Any pilot worth his wings should easily be able to handle an engine failure and hand fly at the same time.

Indeed he should but:

a ) there is no point making life harder than it should be by hand flying when a perfectly serviceable autopilot is available (it's not safer to hand fly, so why do it?),

b ) changing the roles of the two pilots (PF to PNF and vice versa) in the middle of an engine problem also complicates the issue by making the pilots re-jig their mind-sets at a tricky moment.

c ) relying upon the PNF to identify the failure and not checking yourself means that no-one is cross checking. By his own admission the Captain looked at the engine instruments but did not gain from them a clear indication of the problem.

All three of the above go against general UK airline industry practice.
There were a whole pile of other factors associated with the incorrect identification too.

Back in the old days, pilots sat on the outside and got covered in oil and froze - do you want to go back to that idea, too? . There are no Brownie points or extra money to be had from doing it the hard way.

I would suggest to you that as the Canberra had no autopilot, the average Canberra pilot got a lot more hands on time - but doesn't have to worry about passenger comfort, Passenger safety and can bang out if necessary! How many Canberra crews have died just practising asymmetric flying under controlled conditions? The answer will be a shockingly high number if you work it out. Given a decent autopilot, the late Stn Cdr from Wyton would probably still be alive.

Your argument holds as much water as a collander.

Crews train in the sim to deal with engine failures whilst hand flying - but should use the AP in the air if it's available as it reduces workload. You are clearly NOT and airline pilot as you are out of touch with airline training standards and SOPs.

[moggiee]

Originally Posted by Zorst

And I suppose that the students in your MCC/CRM training are magically exempt the environmental capture involved in being on the course, and thus don't come round to the conclusion that the crew did not perform well because they know it's what's expected of them in their environment...

You clearly didn't understand my post.

The students usually believe that the Kegworth crew were harshly treated by the AAIB - usually because they only have half the story (mostly folklore). Once presented with FACTS they come to their own conclusions - I don't force my opinions on them as that would be bad MCC!

[Zorst]

Not at all, they suffer the environmental capture that your teaching environment intends to subject them to. Quite simple if you think it through...

If CRM works, show me the reduction in the accident rate which tracks the introduction and devlopment of CRM. You can't, because there isn't one, and the movement in the accident rate tracks not this factor, but technology, pure and simple.

[lomapaseo]

If CRM works, show me the reduction in the accident rate which tracks the introduction and devlopment of CRM. You can't, because there isn't one, and the movement in the accident rate tracks not this factor, but technology, pure and simple.

How interesting simple.

I always thought that it simply tracked the inverse of GNP

[moggiee]

Originally Posted by Zorst

If CRM works, show me the reduction in the accident rate which tracks the introduction and devlopment of CRM. You can't, because there isn't one, and the movement in the accident rate tracks not this factor, but technology, pure and simple.

If you care to check the stats from the NTSB, AAIB, NASA, FAA and CAA etc. you will find that (according to those organisations) the percentage of accidents attributed to human factors has remained at around 70-80% for 30 years or so. So, if you look at percentages, CRM has done nothing.

However, look deeper and you will see that the OVERALL accident rate (including Human Factors, Tech, ATC, Weather etc) has dropped by about 50% over the same period.

So, given that information, you can see that the number of accidents caused by human factors over that time has fallen by a half.

I can't be bothered to find you the links - you'll only tell me that the NTSB/AAIB/NASA etc are lying and that you know better.

One last thing - if you fly for an airline, could you tell me which one it is so that I can avoid it in future?

[Zorst]

the OVERALL accident rate (including Human Factors, Tech, ATC, Weather etc) has dropped by about 50%

Yes, it has. This is because of technology. Modern, less risky aircraft, replacing older, riskier, ones, plus the introduction of some specific technology (GPWS being a fine example). There are some fine graphcal analyses of this doing the rounds in the worlds of academia, but as you said:

I can't be bothered to find you the links

You also said, quite rightly,

CRM has done nothing

[moggiee]

Zorst - please have the decency not to misquote. As you would be clear if you had the courtesy to quote me fully, CRM has not changed the PERCENTAGE of accidents caused by human factors, because the 50% reduction in human factors related accidents has been matched by similar improvements in other areas.

I also said that I couldn't be bothered to find you the links BECAUSE YOU WOULD NOT BELIEVE THE EVIDENCE. I was obviously right.

Your reply clearly indicates that I was right in my assessment of you - you clearly DO believe that you know better than the NTSB, NASA, AAIB etc. You are a classic example of the closed minded, arrogant dinosaur for whom CRM training was invented. Unfortunately, like most of those dinosaurs, you are too closed minded and arrogant to realise that. Enjoy your life in the 1950s.

I sincerely hope that you are a ) not in an airline seat and/or b ) close to retirement age.

The industry does not need people like you.

May I repeat my previous question: if you ARE an airline pilot, please let me know which airline so that I may book my ticket with someone else?

Finally, your misquoting of my post is an example of bad "netiquette" and is the sort of behaviour which is regarded as being discourteous and rude. That does rather prove the point in my favour!

I shall waste no more time on you - you are obviously beyond saving.

[rogerg]

See post 18.

[nojh]

Kegworth B737 crash / Blast from the past

I find it sad that none of you actually know the truth about the lead up to this accident! I was a personal friend of the Kegworth Cpt who crashed and I had actually trained the SFO,highly intelligent on his PPL studies and his twin rating and employed him as a pilots assistant on C404 Data post flights ex Egaa .C404 covered in snow and ice we always got to Luton.Did we ever.

BMA

Training on the A/C B737/400 was absolutely minimal,the Cpt at Kegworth was a Dc9 pilot the F/o flew the Shorts 360,their conversion to the B737,was woefully inadequate.

1179 flight items /circuits was conducted by an Ire/Tre who a long time previous , had been an instructor examiner on the B 707. This man decided that his prior B707 priveledges on the 707 entitled him to the same priveledges on the B 737.He signed their licences,he had no right to do so! Absolutely no right to do so!

The first revenue B737 BMA flight from EMA, was almost cancelled by the CAA,because they suddenly realised the the operating crew were not by CAA standards legally qualified to operate the A/C.

The pandemonioum in the crew room was amazing .Present ,Caa Pilot /CAFU Fcl .Boeing pilots, Bma pilots ,and "HARD RON" the fictitous Ire/Tre. The arguments were horrendous,it was horrible they were all shouting.

The solution/Last minute desperate/solution.

A Boeing pilot would be the Cpt,for the circuits at EMA./1179 items.
Hard Ron would be tested by the Caa pilot sitting on the jump seat.
so that he could legally become an Ire/Tre,on the B 737/400,to sign out his inaugural BMA 737/400 flight revenue earning flight from EMA.
Two hrs later they landed.The Caa /CAFU signed out 'Hard Ron' who signed out the BMA Cpt/Sfo. Oh God what a mess! Boeing pilot said U shure do things different in the UK,sort of cart before the horse!

The Kegworth Crash.

The engine failed on climb out Lhr over Windsor Castle the flight deck wanted to to land back SAP @ LHR,Flight Ops Ema insisted they fly to EMA.that was the start of a crash that killed 70 plus passengers.

Bad PR for BMA if you land at LHR fly to EMA keep it quiet Hard Ron and Sir MByou killed these people,

How do I know I was a BMA PILOT.

Forget the CRM MCC Engineeres and all the rest of you wannabes, the crash was caused by BMA BULLIES

Pilots and CPTS do not make decisions in BMA Head Office Does.

PPS

Hard Ron was banned from flying B707s to USA because he tried to Jump start a 707 three times on the runway .What about the brakes hard RON,
Hard RON was banned from the USA.

Later in my life @ B/ Seattle B757 course/Boeing were so disgusted by Hard Ron and their conduct they were withdrawing the 737 from BMA.

Pratt and Whitney also were with drawing their engines from BMA Dc9 fleet.What a mess.

Kegworth was NOT THE PILOTS FAULT,NOJH WAS A BMA PILOT OH DEAR What a mess.

[Old Fella]

NOJH's Story

If, as claimed by NOJH, the sequence of events leading to the PIC of the B737-400 involved being endorsed on type is valid the whole "gaggle of geese" involved share the blame. If the type training was "woefully inadequate" the pilots should have stood their ground and insisted on "adequate" training. That said however, at the end of the day the responsibility for the safety of the aircraft and crew is squarely on the shoulders of the Captain.

If the reports which I have read are to be believed, the root cause of the accident was the mis-identification of the engine which had suffered loss of part of a fan blade, which led to the shutting down of the "good" engine by mistake. The reasons why this mis-identification happened may be numerous. The decision as to the most suitable place to land was that of the Captain. There is absolutely no justification for commercial or company reputation considerations over-riding the appropriate safety considerations. Had the correct engine been identified in the first instance and it been shut-down the outcome would, or should, have been vastly different.

[Old Fella]

Windmill starts

Windmill starts work fine in a C130, but not so in a B707, as alleged to have been attempted by "Hard" Ron. I heard a similar story supposedly involving a BA B747 at Karachi. Story had it that the crew, some of whom were ex-C130, tried to start a RR RB211 using the "Windmill" method. Trip fuel and pax on board. Failure after three attempts. Resulting in brake burn out with fire. A quick look at the QRH for Airstart would have shown "Airstart at speeds below 250 KIAS will require starter assistance" which would also apply to a "windmill" attempt. The yarn is probably untrue. If anyone knows whether or not this did happen you may care to let me in on the facts.

[fireflybob]

The Boeing QRH then (and now) states that in the event of vibration to retard the thrust lever until the vibration ceases (if necessary to idle). If the vibration continues (highly unlikely at idle) Boeing stated "other engine problems may be indicated".

So, in my opinion, it was procedurally incorrect to shut the engine down in the first place, given that the engine was misidentified.

But like the holes in the proverbially cheese model there were many factors in the Keqworth accident. What about the lack of certification of the engine in that airframe type - engines shouldnt throw blades! But in our business sometimes s**t happens!

It was somewhat ironic that the failure occurred when at height over EMA. If they had been in the cruise on their way to Tenerife over the water and shutdown the wrong engine they would have attempted to stabilise at a lower level, increased the thrust on the offending engine, recognised the error and then had time for a relight on the good engine.

"Mistakes" were made that night but to some extent this accident was a result of the "system" and culture existing at the time.

[lomapaseo]

The Boeing QRH then (and now) states that in the event of vibration to retard the thrust lever until the vibration ceases (if necessary to idle). If the vibration continues (highly unlikely at idle) Boeing stated "other engine problems may be indicated".

So, in my opinion, it was procedurally incorrect to shut the engine down in the first place, given that the engine was misidentified.

But like the holes in the proverbially cheese model there were many factors in the Keqworth accident. What about the lack of certification of the engine in that airframe type - engines shouldnt throw blades! But in our business sometimes s**t happens!

There is a difference between vibration indications which are displayed on a gage within the cockpit and vibration which is suddenly felt in the cockpit. Vibration gages alone are not reliable indicators of an engine malfunction anymore than fire detectors in a cargo hold a reliable indicator of a fire. For a variety of reasons associated with the gage and detection means, false indications are common. Thus it's important to follow recommended procedures regarding the engine to ascertain the extent of the problem before giving up on the engine and turning off not just the thrust but the accessories that go with it.

However step changes in vibration felt through the airframe are genuinely real and as such a scan of the engine gages over several seconds would confirm if a specific engine was involved.

Regarding the cause of the blade failure itself. Engines are not certified not to fail (sorry for the double negative, but that's my point) They are however certified to be able to be shut down safely within a reasonable time frame (like 20-30 secs). I don't recall that there was a shortfall in this regard associated with the Kegworth accident.

[fireflybob]

There is a difference between vibration indications which are displayed on a gage within the cockpit and vibration which is suddenly felt in the cockpit. Vibration gages alone are not reliable indicators of an engine malfunction anymore than fire detectors in a cargo hold a reliable indicator of a fire. For a variety of reasons associated with the gage and detection means, false indications are common. Thus it's important to follow recommended procedures regarding the engine to ascertain the extent of the problem before giving up on the engine and turning off not just the thrust but the accessories that go with it.

lomapaseo, yes I agree. If I recall correctly one of the issues was that the vib indicators on older engines were unreliable (when I was on the B707 I remember the flight engineers saying they were a waste of time!) but the vib indicators on later a/c are much more reliable. This was not covered in training. Obviously all factors should be taken into account before shutting an engine down (easy to say when you are on terra firma but when you are in the hot seat.....)

Regarding the engine certification I recall that the thrust on the engines had been increased but the full certification process had not been applied in this case with respect to that engine being in that a/c. Maybe I recall incorrectly but my basic point is that modern engines shouldnt lose blades and that this was part of the error chain. You could say another part of the chain was the mickey mouse vib guages fitted to the early B737-300s.

[lomapaseo]

Regarding the engine certification I recall that the thrust on the engines had been increased but the full certification process had not been applied in this case with respect to that engine being in that a/c. Maybe I recall incorrectly but my basic point is that modern engines shouldnt lose blades and that this was part of the error chain. You could say another part of the chain was the mickey mouse vib guages fitted to the early B737-300s.

These are kind of softer issues somewhat subjective to one's opinion.

I've already commented on the reliability of things like vibration meters and smoke/fire detectors. We learn to live with them because without them we're even more in the dark.

I believe what you are getting at with the engine installation might be the normal course of growth/design changes within a certified installation and then walking into a new problem.

There is lots of room for argument on both sides. The certification doesn't really prove anything. It does a pretty good job of assessing relative safety. In spite of passing a few hundred test points during certification there are still numerous parts of the perceived acceptable envelope that are not tested until millions of flight hours. The CFM56 engine ran into this and so have lots of other engines. However, the certification of the installation anticipates this by designing tolerance to the blade loss event itself, for whatever reason.