Company Lip service to Go-around flying skills
Join Date: Jun 2000
Location: last time I looked I was still here.
Posts: 4,507
Likes: 0
Received 0 Likes
on
0 Posts
I understand how the automation failed to do its job properly, but fail to see why the crew were unable to take control of the aircraft using basic flying skills and if need be, a little muscle.
That question has been asked & debated about on here for numerous scenarios; the question is oft repeated, but a definitive answer is still awaited, or rather implemented policy. The answer may be well understood, but not applied by operators. However, with inside and historical knowledge of Thomson, they are one of the more 'manual flight encouraged' airlines.
That question has been asked & debated about on here for numerous scenarios; the question is oft repeated, but a definitive answer is still awaited, or rather implemented policy. The answer may be well understood, but not applied by operators. However, with inside and historical knowledge of Thomson, they are one of the more 'manual flight encouraged' airlines.
Join Date: Jun 2013
Location: Or-E-Gun, USA
Posts: 326
Likes: 0
Received 0 Likes
on
0 Posts
If the reports are accurate, it sounds like the crew (entire company?) needs to revisit the subject of COMMUNICATION and COORDINATION in a multi-crew environment. IMO, there is NO EXCUSE for one pilot - even the commander - doing something without informing the other pilot. Got to TALK boys and girls. TALK to each other! That is what Multi-Crew is all about!
Full power low weight GAs are a dangerous manoeuvre. We don't practice them often and they often go wrong. LOSA data showed that one in 10 result in an undesired aircraft state, but I think the rate is probably close to 1 in 5. peekay4 mentions the B757 incident at Oslo which was so very nearly a crash. The crew were subject to the somatogravic illusion which is human limitation. We have not evolved to assess prolonged acceleration and can easily misinterpret it as pitch up. In the high energy GA, the AP is your friend.
In the Thompson case, it was sensible to have the AP engaged. The question that needs to be asked is why the AT didn't command the power required. Intervention from the PF would have resolved the issue, but in the high workload situation of the GA, it would have been best if it had responded as it should.
In the Thompson case, it was sensible to have the AP engaged. The question that needs to be asked is why the AT didn't command the power required. Intervention from the PF would have resolved the issue, but in the high workload situation of the GA, it would have been best if it had responded as it should.
The crew were subject to the somatogravic illusion which is human limitation. We have not evolved to assess prolonged acceleration and can easily misinterpret it as pitch up
If that were true, then one must ask why aircraft carrier pilots who are catapulted at night or in IMC or conduct go-arounds or "bolters," are not crashing in their thousands. The acceleration of after-burner take offs are ten times more powerful than a go-around or take off in an airliner.
No. I believe the problem is simply poor instrument flying skill which needs to be ironed out during simulator training. We see this often during simulator training. Crashes during go-arounds occur in simulators due generally to poor instrument flying skills and inappropriate operation of the automatics. These are not excused as the result of somatogravic illusions. Yet in real aircraft accidents poor instrument flying ability is often covered up in favour of the more politically correct and mysterious sounding `Somatogravic Illusion.`
While there is medical evidence this illusion is a human limitation, it is practically impossible to prove after a crash that it was the primary cause of the accident. That is why the illusion is such a convenient scapegoat in accident reports because it is impossible to prove with any certainty.
Dan, 'dangerous', a bit strong; don't want to frighten the poor dears. Challenging, yes, for the reasons outlined.
Challenges are there to be met, anticipated, and managed; beware of surprise - "a landing is an approach without a GA", plan for workload, and simplify procedures (including Nav and ATC - see ASAGA report).
Centaurus, yes illusions are a threat, but more often an illusion can be managed having been previously experienced - basic training?
The 757 and similar aircraft have strong nose up pitching moments with GA power, thus reduce power and manage the pitch control. Unfortunately many pilots have been influenced or even trained by the mantra to fly the aircraft in trim; in the extreme to fly the aircraft with trim, and thus are reluctant to use input large control deflections or experience high control forces.
A significant issue in this event, and others, is expecting the autopilot to take over with the aircraft out of trim. Autopilots have no brain - no situation awareness, limited anticipatory ability, and restricted application of control forced and trim rate (safety features).
If a pilot handed over the aircraft to me out of trim, there was a severe cuffing around the ears; perhaps autopilots should have a similar feature, or at least pilots be aware of the limitations of handing over control to a dumb system.
Challenges are there to be met, anticipated, and managed; beware of surprise - "a landing is an approach without a GA", plan for workload, and simplify procedures (including Nav and ATC - see ASAGA report).
Centaurus, yes illusions are a threat, but more often an illusion can be managed having been previously experienced - basic training?
The 757 and similar aircraft have strong nose up pitching moments with GA power, thus reduce power and manage the pitch control. Unfortunately many pilots have been influenced or even trained by the mantra to fly the aircraft in trim; in the extreme to fly the aircraft with trim, and thus are reluctant to use input large control deflections or experience high control forces.
A significant issue in this event, and others, is expecting the autopilot to take over with the aircraft out of trim. Autopilots have no brain - no situation awareness, limited anticipatory ability, and restricted application of control forced and trim rate (safety features).
If a pilot handed over the aircraft to me out of trim, there was a severe cuffing around the ears; perhaps autopilots should have a similar feature, or at least pilots be aware of the limitations of handing over control to a dumb system.
Join Date: Jun 2000
Location: last time I looked I was still here.
Posts: 4,507
Likes: 0
Received 0 Likes
on
0 Posts
[I]thus reduce power and manage the pitch control.
Indeed; as I've often emphasised to students, "power can be your friend, or very unfriendly."
Some instructors were taught to teach a G/A is full power at all times. Ouch. Thrust is a variable when needed, and over thrust during G/A is a real gotcha.
Indeed; as I've often emphasised to students, "power can be your friend, or very unfriendly."
Some instructors were taught to teach a G/A is full power at all times. Ouch. Thrust is a variable when needed, and over thrust during G/A is a real gotcha.
Join Date: Oct 2004
Location: Near sheep!
Posts: 915
Likes: 0
Received 0 Likes
on
0 Posts
Gonna stick my neck out here, but I feel incidents such as this would be avoided if the SOP was simply "fly the a/c up to the G/A altitude".
Without the confusion of following infrequently practised procedures, it would be a walk in the park to apply a moderate amount of thrust, level the a/c, tweak the thrust as appropriate and simply hand fly it back up, calling for gear and flap as appropriate.
I guarantee any competent pilot would make a much cleaner job of it rather than trying to obey flight directors and rigorous memory items with a massively overpowered light a/c like the 757.
In the world we live in, this would never happen though...........
Without the confusion of following infrequently practised procedures, it would be a walk in the park to apply a moderate amount of thrust, level the a/c, tweak the thrust as appropriate and simply hand fly it back up, calling for gear and flap as appropriate.
I guarantee any competent pilot would make a much cleaner job of it rather than trying to obey flight directors and rigorous memory items with a massively overpowered light a/c like the 757.
In the world we live in, this would never happen though...........
Join Date: Sep 2014
Location: Canada
Posts: 1,257
Likes: 0
Received 0 Likes
on
0 Posts
If that were true, then one must ask why aircraft carrier pilots who are catapulted at night or in IMC or conduct go-arounds or "bolters," are not crashing in their thousands. The acceleration of after-burner take offs are ten times more powerful than a go-around or take off in an airliner.
F/A-18C HORNET NIGHT CATAPULT LAUNCH
The Mishap Aircraft (MA) crashed into the water after night catapult launch. The Mishap Pilot (MP) was
well rested and mentally prepared for the Mishap Flight (MF). MP spent significant time troubleshooting
several discrepancies while on deck, all of which were satisfactorily resolved prior to MA launch. Weather
conditions were overcast at 600-1000 ft, creating an extremely dark night under the low overcast. MP
conducted a normal catapult shot with sufficient airspeed for flyaway. Almost immediately after launch, MP
grabbed the stick and easily countered a slight roll to the right due to MA asymmetric condition. MP
gradually applied forward stick during the climb out. After peaking in altitude at 224AGL, the MA
responded to the forward stick by accelerating and following a nose down flight path toward the water. Just
prior to water impact, MP realized he was in extremis and attempted to eject, but was already out of the
ejection envelope resulting in an unsuccessful attempt. MP lost at sea.
Official Cause Factor:
AIRCREW: MP applied improper forward stick inputs during climb out due to the effects of somatogravic
illusion.
...
The F/A-18 mishap presented in this report is not a rare type of mishap. For the past several years, NAMRL has
assisted on at least one case per year of somatogravic illusion in the "fast mover" communities (three such mishaps
in FY2001). Somatogravic illusion mishaps are not always associated with catapult launches, but may also occur in
high performance takeoffs, landings and bombing runs over land.
The Mishap Aircraft (MA) crashed into the water after night catapult launch. The Mishap Pilot (MP) was
well rested and mentally prepared for the Mishap Flight (MF). MP spent significant time troubleshooting
several discrepancies while on deck, all of which were satisfactorily resolved prior to MA launch. Weather
conditions were overcast at 600-1000 ft, creating an extremely dark night under the low overcast. MP
conducted a normal catapult shot with sufficient airspeed for flyaway. Almost immediately after launch, MP
grabbed the stick and easily countered a slight roll to the right due to MA asymmetric condition. MP
gradually applied forward stick during the climb out. After peaking in altitude at 224AGL, the MA
responded to the forward stick by accelerating and following a nose down flight path toward the water. Just
prior to water impact, MP realized he was in extremis and attempted to eject, but was already out of the
ejection envelope resulting in an unsuccessful attempt. MP lost at sea.
Official Cause Factor:
AIRCREW: MP applied improper forward stick inputs during climb out due to the effects of somatogravic
illusion.
...
The F/A-18 mishap presented in this report is not a rare type of mishap. For the past several years, NAMRL has
assisted on at least one case per year of somatogravic illusion in the "fast mover" communities (three such mishaps
in FY2001). Somatogravic illusion mishaps are not always associated with catapult launches, but may also occur in
high performance takeoffs, landings and bombing runs over land.
Source: www.dtic.mil/cgi-bin/GetTRDoc?AD=ADP013854
Simplicity is a good objective, but there are limits.
An SOP to 'fly the aircraft' overlooks the need to adapt the 'standard' to the situation; do pilots have knowledge of the 'when and how to adapt'. These aspects can be primed with a good briefing by considering the differences between the expected situation and that trained for, particularly if training amalgamates GA with engine failure.
Many SOPs are written for the exceptional circumstance; GA, + engine fail, + max wt, + terrain limited. How many accidents have involved some or all of these aspects in combination, vs incidents during a normal GA. Many SOPs are not 'standard', they are abnormal procedures; a GA is just part of normal operation.
SOPs have to be written for the normal, we must train for the normal; brief for the abnormal. The industry needs to develop skills of awareness, planning ahead, knowing when and how to adapt, then review and learn from debriefing.
However there are significant obstacles to this in the training mantra, to always follow SOPs, which may adversely influence and restrict pilots' flexibility and adaptability in those situations when most needed.
Procedure writers need to review SOPs for ambiguity, unpublished assumptions, or specific situations where 'standard' does not apply.
Provide explanation and context; as indicated in #29 'moderate', 'tweak', 'as appropriate'; these also require knowledge of how and when.
... the best laid plans ..... frequently have to adapt to reality.
Things are 'simple' before thinking, but simplicity is only enabled after thought.
An SOP to 'fly the aircraft' overlooks the need to adapt the 'standard' to the situation; do pilots have knowledge of the 'when and how to adapt'. These aspects can be primed with a good briefing by considering the differences between the expected situation and that trained for, particularly if training amalgamates GA with engine failure.
Many SOPs are written for the exceptional circumstance; GA, + engine fail, + max wt, + terrain limited. How many accidents have involved some or all of these aspects in combination, vs incidents during a normal GA. Many SOPs are not 'standard', they are abnormal procedures; a GA is just part of normal operation.
SOPs have to be written for the normal, we must train for the normal; brief for the abnormal. The industry needs to develop skills of awareness, planning ahead, knowing when and how to adapt, then review and learn from debriefing.
However there are significant obstacles to this in the training mantra, to always follow SOPs, which may adversely influence and restrict pilots' flexibility and adaptability in those situations when most needed.
Procedure writers need to review SOPs for ambiguity, unpublished assumptions, or specific situations where 'standard' does not apply.
Provide explanation and context; as indicated in #29 'moderate', 'tweak', 'as appropriate'; these also require knowledge of how and when.
... the best laid plans ..... frequently have to adapt to reality.
Things are 'simple' before thinking, but simplicity is only enabled after thought.
PK 4, beware the 'Americanism' of using 'a leading killer', - one of many causes, in the context of 'the leading cause', i.e. top of the list. The report does not support the view that this illusion(SD) is top of the list. The discussion relates to a model, computer simulation, as an aid to investigation. Take care not to over rate the problem of SD in commercial aviation.
However, it does warrant attention, but it may be more beneficial to focus on real aircraft demonstration vs forum discussion and false claims of training simulators.
However, it does warrant attention, but it may be more beneficial to focus on real aircraft demonstration vs forum discussion and false claims of training simulators.
Join Date: Jun 2000
Location: last time I looked I was still here.
Posts: 4,507
Likes: 0
Received 0 Likes
on
0 Posts
Many SOPs are written for the exceptional circumstance;
SOPs have to be written for the normal, we must train for the normal; brief for the abnormal.
Is there not a slight contradiction there? SOP's can be written for the norm, and can also be written for the simple non-normal and some expected emergencies. These are trained and checked ad infinitum, so help me god. The accidents happen when events happen outside these scenarios and pilots are left grasping at straws in the dark.
It could be that you can become 'over-SOP'd' & 'under-airmanshiped & under-trained & under-educated' in your a/c.
IMHO pilots should be trained in all the aspects of how their a/c was designed and what it can do, and its systems. There will be basic simple SOP's for the basic simple manoeuvres. Outside those the crews should have full confidence and discretion to use whatever weapons the a/c & its systems offer them at their disposable to achieve the task in hand. Not all G/A's are the same. The crew should be able to act as pilots and not trained monkeys where there is a 1 size fits all SOP. That is what I find too much in todays TR courses. Too many SOP's not enough education. Too much who, what & when and not enough how & why and other options.
SOPs have to be written for the normal, we must train for the normal; brief for the abnormal.
Is there not a slight contradiction there? SOP's can be written for the norm, and can also be written for the simple non-normal and some expected emergencies. These are trained and checked ad infinitum, so help me god. The accidents happen when events happen outside these scenarios and pilots are left grasping at straws in the dark.
It could be that you can become 'over-SOP'd' & 'under-airmanshiped & under-trained & under-educated' in your a/c.
IMHO pilots should be trained in all the aspects of how their a/c was designed and what it can do, and its systems. There will be basic simple SOP's for the basic simple manoeuvres. Outside those the crews should have full confidence and discretion to use whatever weapons the a/c & its systems offer them at their disposable to achieve the task in hand. Not all G/A's are the same. The crew should be able to act as pilots and not trained monkeys where there is a 1 size fits all SOP. That is what I find too much in todays TR courses. Too many SOP's not enough education. Too much who, what & when and not enough how & why and other options.
Join Date: Sep 2014
Location: Canada
Posts: 1,257
Likes: 0
Received 0 Likes
on
0 Posts
I wrote "a leading killer" for military pilots and I mean it. During Desert Storm the US Navy lost 15 aircraft in non-combat accidents. 7 of those 15 involved SD.
From the US Navy:
From the US Air Force:
From the US Navy:
Spatial Disorientation (SD) is an aviator’s misperception of the attitude, position, or motion of his/her aircraft relative to the Earth’s surface and gravitational vertical. SD is a serious threat to flight safety and is the leading aeromedical cause of Class A mishaps in Naval aviation. SD is also a leading killer across the DoD and in civilian aviation as well.
7.8. Spatial Disorientation (SD). SD has proven to be a leading killer of F-16 pilots. Although SD is most common at night or in IMC, it can and has happened in day VMC. Reference AFPAM11-417 for information on the causes of SD, how to avoid it, and how to mitigate its consequences.
the US Navy lost 15 aircraft in non-combat accidents. 7 of those 15 involved SD.
From the US Navy:
From the US Navy:
Over many years as a current pilot I have seen countless accident reports where the investigators opined the most likely cause of similar accidents involving take off or a go-around (night/IMC)was SI . They make an educated guess it was an SI problem; but that is not factual as it cannot be proved beyond doubt.
Last edited by Centaurus; 24th Nov 2016 at 04:46.
Having known a number of carrier pilots, including my brother, everyone would say, if you aren't deeply SD'd on a bolter back in dark clouds, you're inhuman. It takes a lot of self-discipline and experience to handle it well. I've sworn the tanker was doing all kinds of weird maneuvers while on the boom in and out cloud at night.
Join Date: Sep 1999
Location: United Kingdom
Posts: 929
Likes: 0
Received 0 Likes
on
0 Posts
IMHO part of the problem is over pedantic SOP. For instance taking an A 330 out of xxxx with a 2000ft level off & a sop for power reduction of 1500ft. Me says to pf please feel free to select clb pwr once wheels up. Answer from pf NO that is not sop. Me says ok whatever you wish to do you are not to bust the level or the flap speed. Anyway atc changed height clearance on the take off roll. Would have. Power is part of the flying controls & sometimes total adherence to sop is dangerous but the fear of the QAR is causing lack of intelligent thought and the ability to actually control the aeroplane.
Thread Starter
Join Date: Apr 2005
Location: Australia
Posts: 1,414
Likes: 0
Received 0 Likes
on
0 Posts
the fear of the QAR is causing lack of intelligent thought and the ability to actually control the aeroplane
... a slight contradiction there?
Yes, but who is expected to resolve the contradiction, and when. Most likely the crew at the time of an event, and in real time.
A well crafted SOP could reduce the mental workload; also appropriate training should enable greater thinking capacity in demanding situations.
Is it easier for pilots to relate to a change of action when moving from 'a norm' - the SOP for an 'everyday' GA, to that of judging the need for increased thrust in a more extreme situation; or
the alternative of having an SOP which covers all situations, and then having to judge the need to change activity for the more likely encountered 'normal' situation? (But not to fool ourselves that extremes cannot happen.
A danger with the latter option, which may apply to many SOPs, is that pilots may be tempted to fit a situation to the SOP because the SOP is known to cover 'all' of the extreme combinations in a situation (as defined by someone else). This bias can be reinforced if training influences the 'expected' norm (extreme failure case), thus reducing the need to understand the situation, e.g. GA training 'always' involves engine failure.
There are probably good psychological arguments for one view or the other. One powerful argument is that of framing a situation, or 'nudging' people toward a particular behaviour. However, do the so called experts of behaviour - or self styled managers, actually consider that the line pilots are the real experts, particularly those who have experienced situations with the use of 'non-normal' SOPs in normal situations.
Do SOPs reflect the real, practical world which pilots operate in, or are they written based on theoretical premise or regulatory need; especially if the latter is biased by the theory.
Re considering line pilots as a source of expertise, see the ASAGA study * which identifies problem areas and solutions from a pilots perspective (section 3., and page 38 onwards). Also note the differences in severity rating between pilots and instructors for the same problems. Are instructors being overly sensitive to pilot performance, or are pilots operating so close to the limit of their mental performance they are unaware of the high workload, and thus more liable to sudden loss of mental capacity enabling awareness and control ... surprise.
An interesting analogy is that choosing to use SOPs to define a situation might involve similar mental processes to those involved in illusions.
SD, SI, relate to 'confused' senses; perhaps poorly crafted (weakly framed) SOPs add to mental workload and confusion, which results in an illusion of awareness, understanding, and being in control.
"The first principle is that you must not fool yourself, and you are the easiest person to fool." Richard Feynman.
* ASAGA, https://www.bea.aero/etudes/asaga/asaga.study.pdf Aeroplane State Awareness during Go-Around.
Yes, but who is expected to resolve the contradiction, and when. Most likely the crew at the time of an event, and in real time.
A well crafted SOP could reduce the mental workload; also appropriate training should enable greater thinking capacity in demanding situations.
Is it easier for pilots to relate to a change of action when moving from 'a norm' - the SOP for an 'everyday' GA, to that of judging the need for increased thrust in a more extreme situation; or
the alternative of having an SOP which covers all situations, and then having to judge the need to change activity for the more likely encountered 'normal' situation? (But not to fool ourselves that extremes cannot happen.
A danger with the latter option, which may apply to many SOPs, is that pilots may be tempted to fit a situation to the SOP because the SOP is known to cover 'all' of the extreme combinations in a situation (as defined by someone else). This bias can be reinforced if training influences the 'expected' norm (extreme failure case), thus reducing the need to understand the situation, e.g. GA training 'always' involves engine failure.
There are probably good psychological arguments for one view or the other. One powerful argument is that of framing a situation, or 'nudging' people toward a particular behaviour. However, do the so called experts of behaviour - or self styled managers, actually consider that the line pilots are the real experts, particularly those who have experienced situations with the use of 'non-normal' SOPs in normal situations.
Do SOPs reflect the real, practical world which pilots operate in, or are they written based on theoretical premise or regulatory need; especially if the latter is biased by the theory.
Re considering line pilots as a source of expertise, see the ASAGA study * which identifies problem areas and solutions from a pilots perspective (section 3., and page 38 onwards). Also note the differences in severity rating between pilots and instructors for the same problems. Are instructors being overly sensitive to pilot performance, or are pilots operating so close to the limit of their mental performance they are unaware of the high workload, and thus more liable to sudden loss of mental capacity enabling awareness and control ... surprise.
An interesting analogy is that choosing to use SOPs to define a situation might involve similar mental processes to those involved in illusions.
SD, SI, relate to 'confused' senses; perhaps poorly crafted (weakly framed) SOPs add to mental workload and confusion, which results in an illusion of awareness, understanding, and being in control.
"The first principle is that you must not fool yourself, and you are the easiest person to fool." Richard Feynman.
* ASAGA, https://www.bea.aero/etudes/asaga/asaga.study.pdf Aeroplane State Awareness during Go-Around.