ANA Japan roll incident.

[Denti]

Post 9/11. Operation is detailed in your FCTM.

[A37575]

Coupled with AF447, I would love to know why incompetence of this level isn't being spotted earlier (e.g. in the sim)

First of all, the vast majority of simulator type rating training and recurrent training is with full use of automatics. Thus, incompetence at manual flying would rarely show up unless an inadvertent unusual attitude just happened to occur. Apart from specific non-normals (manual reversion for example) hand flying is usually confined to the last part of an ILS and even that would be with FD and AT engaged.

Secondly, most unusual attitude training ( if practiced at all) is kept within the Boeing definition of unusual attitudes which are clearly stated in the FCTM. In fact, these are quite benign attitudes and easily recoverable. Rightly or wrongly, recovery in IMC from inverted nose down flight is rarely practiced in the simulator and it is left to the pilot to learn by reading from the FCTM and QRH sections rather than practicing in the simulator.

To have found himself in the extreme attitude described in the incident report, the copilot must have been way behind the aircraft to have allowed it to develop into such a serious Upset. In fact, it is most probable the copilot himself applied erroneous manual inputs to the flight controls that exacerbated the initial problem caused by inadvertent trim input.

With most simulator training confined to box ticking exercises designed to minimize training costs, it is no wonder that pilots are rarely given the opportunity to assiduously practice manual flight manoeuvres that require good skills such as Jet Upset and stall recoveries at high altitude as well as crosswind landings on slippery runways.

To make things more difficult for new pilots, it is rare to have a simulator instructor set a good example by personally demonstrating how to fly these maneouvres, before handing over control to the student to have a go. The assumption seems to be that if the student has a commercial pilot's licence there should be no need for an instructor to demonstrate. Not all students are aces and an instructor demonstration may be needed rather than a box quickly ticked.

[DC-ATE]

Denti-
Post 9/11. Operation is detailed in your FCTM.

Well, we had the doors locked long before "9/11", so don't know why they had to change the design of the switch. There was NO way to have this happen with the switch/lock the way it used to be.

As to my "FCTM".....it's long gone, as I retired over 20 years ago !!

[silverstrata]

Some observations for confirmation of what people have already been saying here.


a. Some 737s have the door knob and rudder trim right next door to each other.

b. The knob has to be held over, until the door is opened. That can easily be 5 - 10 seconds - easily enough overpower the autopilot for an upset.

c. The presence of a flight attendant on the flight-deck would not assist. Rather it would be a further distraction, and the f/o chats her up.

d. Requiring flight attendants on the flight deck can be counter-productive. You then have to ask 'sir' before you can go to the toilet. And the reply will often be "piss off, I'm busy with the service" (low standards airline, low standards fight attendants).

e. Some f/os would not notice if the aircraft was flying upside down. Autopilot is engaged, so the attitude indicator must be lying. (See also the lack of flying skills in the AF 447 incident, or the Indian 737 upset.).

f. The 737 is an ergonomic disaster.

g. The hydraulic pumps are regularly turned off, instead of the ant-ice switches (why are ant-ice switches 'guarded' like the more important hydraulic switches?)

h. Every aircraft is different, with many switches in different positions. Bit of a pain, when you are expecting to feel one switch, and find something completely different. Then there are also differences between the classic and NG, to add further confusion.

i. The proposal that Boeing will keep the same flight deck for the next 30 years, is an aviation tragedy. In 30 years time, it will be like airlines using the Vickers Vimy today, in the 21st century. May Boeing be economically punished for their stupidity, with airlines turning away from the 737.

j. How can a commercial aircraft without a viable control split facility still be produced and flying in the 21st century?


.

[Willit Run]

Maybe the JCAB needs to increase the ground school time from 6 months to say???? 12-14 months to cover this most perplexing,complicated,intensive task.

[Fratemate]

All this hand-wringing about 737 ergonomics and re-inventing the wheel, with cabin crew coming in while one person is on the flight deck etc is complete bolleaux. The simple matter is Numbnuts didn't look before he operated the switch; end of story. What do you do when you're going to put the eng anti-ice on? Do you randomly reach above your head and turn on a switch that feels about the right place? Of course you don't. Likewise, when opening the cockpit door, do you reach down to the centre pedestal and twist a big round knob that is in a different place, looks and feels nothing like the door opening switch, without looking? Of course you don't. This is purely and simply down to FO Numbnuts not looking before doing and it doesn't need the rest of aviation to be re-invented; rather he needs a good kicking (read educating) and instructions into 'more study' and 'more highlighting' (Japan-based pilots will understand the last bit) .

[ATC Watcher]

The simple matter is Numbnuts didn't look before he operated the switch;

Easy , this is investigation done like 30 years ago ' the operator has srewed up . no need to change anything ".

I do not know how many millions flight hours the 737 has,and how many tens of thousands crews have flown it since 9/11, and this appears to be a one-off incident. The question is :can it happen again with a different "Numbnuts" ?
If the answer is no, then send the numbnuts to re-education .
If the answer is yes, then change something.(i.e relocate the door unlock knob elsewhere , preferably in a standard location )
End of the story.

[B412]

Airmanship

There isn't an aircraft type of any description that does not have the possibility of a problem from incorrect switching.

The adage "Identify", "Confirm" and then "Select", was taught years ago, and still applies. Those simple steps can be done multi crew, or single crew as was the case here.

A lack of basic airmanship seems to be the culprit here.

[silverstrata]

So, somehow, customers were permitted to reposition the newer small Rudder Trim Control rotary knob much further forward.

Lack of future planning by Boeing, leaving no room on the pedestal. Then along comes an acars PFM box, and nobody knows where to put it. So it gets jammed at the back, and the rudder trim knob gets positioned further forwards.

And that can be half the problem. You look for a rotary knob half way along the pedestal, which is nowhere near the trim knob, and then find the trim knob instead, because someone has moved it.

737 pedestals are pick'n'mix, because no two aircraft are the same. You can spend several minutes trying to get an ADF frequency out of an HF box, if you are not careful.

BTW - why do we still have ADFs in the 21st century? Can an ILS DME not beep at 4 dme, to mark the OM?


.

[rogerg]

BTW - why do we still have ADFs in the 21st century? Can an ILS DME not beep at 4 dme, to mark the OM?

Many places require you to perform an ADF approach, maybe that's the reason.

[Denti]

Don't need an ADF to fly a NDB approach, as tuning, receiving, identifying and displaying the underlying NAVAID is not required anymore for non precision approaches on the 737.

However, many ILS installations do not have a DME co-located with the ILS.

[Plectron]

Gee, with all those changes to the B737, it's truly amazing anyone can fly one safely. That darn old MD-80 and all the derivatives must be a devil for all the DC-9 guys to deal with too.

The fuel control knobs are right next to the props on many piston aircraft.

My head is spinning with the possibilities there.

[stepwilk]

Back in the old days--yeah, my days--many controls had distinctive shapes. The landing gear handle ended in a nicely molded miniature wheel and tire, the flap handle was a segment of a flap, the engine levers each had differently shaped (and colored) handles. Obviously we can't do that with six zillion knobs and switches in a 21st century air transport aircraft, but at least there was a time when people were thinking about it.

On the other hand, how many people retracted the gear when they thought they had the flaps? Or leaned the mixture past lean cut when they thought they were dialing the props back?

[renard]

I fly planes with an electric rudder trim. If you turn the trim knob full scale at cruise speeds for more than a second the seat of your pants will tell you that the plane is yawing big time. How can you loose the plot so much that you can hold that switch for 29seconds?????

[fdr]

How can you loose the plot so much that you can hold that switch for 29seconds?????

because we/they and you are human.


That is the failing, and also the saving grace... as computers also suffer form the problem of being computers... ie divide by zero etc... BSOD... "wait one..." "re-syncing".


Bad design abounds in the B737, it is not a glorious bit of design, but hard to argue with the market, it has been effective.

[silverstrata]

>>Many places require you to perform an ADF approach,
>>maybe that's the reason.

That's not the point. The point is that airfields that cannot afford a minimum of a VOR (preferably an ILS) should be off-limits to commercial traffic. This would free up two slots in the center pedestal of every commercial aircraft in the world, and make things much safer. ADF approach for an A380? You must be joking.

We started off with ADFs, in the '30s (?). Then we had VORs, ILSs, INS and GPS. You would have thought that the first on the list could be deleted by now. And an ever more crowded and complicated cockpit inevitably means ever more scope for errors. GIGO works on flightdecks, every bit as much as it does for computers. Witness the French A320 three-degree crash.

Its like comms boxes. Some numbskull decided to add yet another digit to the box, making frequencies more and more unintelligible (who was this g!t?). When any competent ergonomicist would notice that the number of frequencies (if we used all channel numbers) only required 4 digits, not 6. So frequency hand-overs are being garbled daily on the airwaves, with the attendent dangers of miss-communication, all because aviation has lost an understanding of KISS.


Not sure what someone meant by not needing an ADF for a non-precision. Dual GPS approaches are not yet authorised, so an ADF will need to be tuned and idented in such cases.

[J4CKO99]

Just a thought, have read some of the thread and can see how this happened fromt he very detailed explanations, but, am I right in saying that the incident would not have occurred in the pre 9/11 world as the cockpit door was not locked back then so the door would just be opened manually by the returning crew member ?

Potentially, to my mind, if that is the case this would be an indirect consequence of 9/11 and the changes that were made, sort of a bit like how Burglar alarms and Anti Virus Software seem to cause as many problems as threats they solve but in a much more serious way.

Would it have gone that way anyway regardless of the terrorist threat ?

[silverstrata]

am I right in saying that the incident would not have occurred in the pre 9/11 world as the cockpit door was not locked back then so the door would just be opened manually by the returning crew member ?

Quite correct. Normally, you would simply open a door-knob, like entering any office. And passengers, trying to find the loo, frequently did.

The Indian 737 upset was another security door issue, that nearly ended in catastrophe. The captain had to wait the full 30 seconds, before the door would open on the security code, while the aircraft was basically out of control. Had ther been no security door, control would have been regained 25 seconds earlier.

Aviation safety is always two steps forward, and one step back, as none of the Goons in the CAA ever think things through. TCAS was another, where the Swiss mid-air was a direct consequence of not doing a full analysis of the possible consequences of this new technology - and so a safety measure ends up killing people. Comms frequencies are the same, as I have just illustrated. The number of times I have heard an aircraft go off frequency because of these complicated numbers, at the most inopportune moment, leaving ATC to struggle with a non-responsive aircraft.


Aviation has long been 'Tombstone Engineering', but it looks as though it has now become 'Tombstone Health and Safety' too.

[stepwilk]

We started off with ADFs, in the '30s (?). Then we had VORs, ILSs, INS and GPS. You would have thought that the first on the list could be deleted by now.

But then how would you listen to the ball game?

[Lord Spandex Masher]

Are you serious?

A five digit number becomes complicated and confusing by the addition of one more digit...which is always either a 5 or a 0?!

Do you get confused between flight level 35 and flight level 350 too?