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Boeing incidents/accidents due to Thrust/Pitch mode mishandling

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Boeing incidents/accidents due to Thrust/Pitch mode mishandling

Old 14th Oct 2018, 14:18
  #61 (permalink)  
 
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Originally Posted by BluSdUp View Post
You are spot on.
The non flying hand belongs on the TL ( minus V1 to ca 400 feet on T/o) for tactile feedback.
Very important on the 738 when trying to slow down on a tailwind approach and or a steeper then 3` glide when heavy.
Now for the Asiana:
First Q:
" How many pilots does it take to trash an aircraft?"
A
"Usually 3, One being an instructor and or super senior"

I am on my first zigar and second coffee , so not quite awake this balmy Sunday morning, so my numbers might be wrong from memory:
The Captain Candidate had 8000 hrs and ALL on A320 and they were sitting him direct into the LH seat to command a 777. He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident.
As mentioned before if THIS was a challenging approach , what about the one Murphy had lined up the first week after line release , on that dark and stormy night , with the toilet on fire!
A systemic fail from the company with at least two marginal crew with that a lack of self preservation.
Blame Boeing!
Why not, they should not have sold it to them in the first place?

Regards
Cpt B
Sorry but, in my opinion, this is total nonsense. The root cause of this specific accident was mainly a lack of understanding of AFDS modes and selections from the PF associated to an incorrect GS from above capture procedure and marginal adherence to company SOPs, very poor PM duties from the instructor and poor assertiveness from the 3rd pilot. PIC time on the A320 is completely irrelevant. When a trainee undergoes a new type rating he/she must work hard to clear his mind of whatever procedure he was doing on the previous type and put maximum effort in system knowledge and operations of the new type, with the advantage like in this specific instance that the trainee is within the same operator so he/she can only focus on the technical aspect of the training.
The instructor on the other hand must be extra vigilant and add to his normal PM duties the instructional inputs. This requires ability and capability to be done to very high standards simultaneously and takes time to develop for every single instructor keeping in mind that PM duties and, more than ever, Capt responsibilities will always have the priority over everything else, in other words You don't end up upside down because You are trying to let the trainee understand.
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Old 14th Oct 2018, 15:29
  #62 (permalink)  
 
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Originally Posted by sonicbum View Post
Sorry but, in my opinion, this is total nonsense. The root cause of this specific accident was mainly a lack of understanding of AFDS modes and selections from the PF associated to an incorrect GS from above capture procedure and marginal adherence to company SOPs, very poor PM duties from the instructor and poor assertiveness from the 3rd pilot. PIC time on the A320 is completely irrelevant. When a trainee undergoes a new type rating he/she must work hard to clear his mind of whatever procedure he was doing on the previous type and put maximum effort in system knowledge and operations of the new type, with the advantage like in this specific instance that the trainee is within the same operator so he/she can only focus on the technical aspect of the training.
The instructor on the other hand must be extra vigilant and add to his normal PM duties the instructional inputs. This requires ability and capability to be done to very high standards simultaneously and takes time to develop for every single instructor keeping in mind that PM duties and, more than ever, Capt responsibilities will always have the priority over everything else, in other words You don't end up upside down because You are trying to let the trainee understand.
It's an odd bit of reasoning to conclude from "must work hard to [avoid X]" where X is a factor that could contribute to an accident in a new type, that X is "completely irrelevant." If it's so irrelevant, then what's the bother working hard over it?
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Old 14th Oct 2018, 15:51
  #63 (permalink)  
 
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Originally Posted by Vessbot View Post
It's an odd bit of reasoning to conclude from "must work hard to [avoid X]" where X is a factor that could contribute to an accident in a new type, that X is "completely irrelevant." If it's so irrelevant, then what's the bother working hard over it?
Sorry but I really do not understand what You are talking about.
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Old 14th Oct 2018, 15:57
  #64 (permalink)  
 
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Originally Posted by sonicbum View Post
Sorry but I really do not understand what You are talking about.
You said that the pilot's previous experience in another type is "completely irrelevant," but in the next sentence said that he "must work hard to clear his mind of" that experience. Both of those cannot be true.
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Old 14th Oct 2018, 16:04
  #65 (permalink)  
 
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Originally Posted by Vessbot View Post
You said that the pilot's previous experience in another type is "completely irrelevant," but in the next sentence said that he "must work hard to clear his mind of" that experience. Both of those cannot be true.
I did not say that "pilot's previous experience in another type is completely irrelevant," but "PIC time on the A320 is completely irrelevant". That should clear up Your uncertainty.
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Old 14th Oct 2018, 16:09
  #66 (permalink)  
 
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Originally Posted by sonicbum View Post
I did not say that "pilot's previous experience in another type is completely irrelevant," but "PIC time on the A320 is completely irrelevant". That should clear up Your uncertainty.
It doesn't. "PIC time" is just a more specific way of describing his previous experience in that type. Maybe you're talking about his SIC time then? Or combination of PIC and SIC time? Anyway, who cares about all the exact particulars. Do you agree or disagree that his habits formed over a substantial amount of experience with the different type might have contributed in his on-the-spot mode confusion?
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Old 14th Oct 2018, 16:53
  #67 (permalink)  
 
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Originally Posted by Vessbot View Post
It doesn't. "PIC time" is just a more specific way of describing his previous experience in that type. Maybe you're talking about his SIC time then? Or combination of PIC and SIC time? Anyway, who cares about all the exact particulars. Do you agree or disagree that his habits formed over a substantial amount of experience with the different type might have contributed in his on-the-spot mode confusion?
Vessbot You keep mixing up different things all together. I was specifically replying to a comment where, amongst others, it was stated that "He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident."
Now in my opinion, in the context of this accident, this has nothing to do for the reasons already mentioned before.

Originally Posted by Vessbot View Post
Do you agree or disagree that his habits formed over a substantial amount of experience with the different type might have contributed in his on-the-spot mode confusion?
of course I do, hence my comments. Again, it is specifically the experience as a Commander that is not specifically relevant in this context, but his overhaul experience on a different type was definitely a threat that was unmanaged by the crew.

Last edited by sonicbum; 14th Oct 2018 at 16:57. Reason: rephrasing
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Old 14th Oct 2018, 17:05
  #68 (permalink)  
 
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Un-learning for better word.

Having done a few 1000 hrs of type rating courses and some line training I would say one of the biggest problem SOME experienced pilots have is forgetting about the " Other" aircraft , when they get stressed.
Had an experienced ATR captain try to use the steering tiller on a xwind T/o during linetraining on a Do328 TP out of Fornebu Oslo.
Fortunately it did not work, would have been catastrophic.

Also had some good fun in the 737 sim watching experienced Airbus, Fokker, MD80 and Dornier pilots try to find the TOGA button on a go around.

Also going direct Long Haul captain from a different SH manufacturer is not a good idea, I think!
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Old 14th Oct 2018, 17:26
  #69 (permalink)  
 
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Originally Posted by BluSdUp View Post
Having done a few 1000 hrs of type rating courses and some line training I would say one of the biggest problem SOME experienced pilots have is forgetting about the " Other" aircraft , when they get stressed.
110% agree on that. I share the same experiences and comments.
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Old 14th Oct 2018, 18:08
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Thanks Vessbot.

Sonicbum.
So, I concentrate on the Big Picture, always. Details are fun, but boring when after all its just a big Piper Seneca with reeeeealy slow engines on it if left at idle on short final.
Eh! ?
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Old 14th Oct 2018, 19:31
  #71 (permalink)  
 
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Originally Posted by BluSdUp View Post
Thanks Vessbot.

Sonicbum.
So, I concentrate on the Big Picture, always. Details are fun, but boring when after all its just a big Piper Seneca with reeeeealy slow engines on it if left at idle on short final.
Eh! ?
Well, don't really agree on that one.
Previously You have written : "The Captain Candidate had 8000 hrs and ALL on A320 and they were sitting him direct into the LH seat to command a 777. He had less then 3000hrs command.
That is pure madness from the Company and the local CAA, me thinks.
THE direct cause of the accident."

This is not about the big picture, it is -IMHO- simply heading in the wrong direction.
The big picture is paramount, we are all happy about that, but during investigations we must focus also on the details, understand why things went the way they did and prevent it from happening again by using the proper countermeasures.
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Old 14th Oct 2018, 22:15
  #72 (permalink)  
 
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Both the big picture and the details are equally important to focus on. I think accident investigation boards are better at identifying the details, which are more tangible and more easily describable. Such as some logic trap in this or that combination of submodes, or a seldom-encountered interaction of A and B systems... things that can be pointed to and shown that happened in a particular moment on the flight. And these can be (and should be) fixed so as not to contribute in a future accident.

But why the pilot acted or failed to act in a particular way? That's fuzzier and harder to identify. It has to do with trends, habits, and mental states. It's harder to identify as happening at X moment in time and setting off the chain of events Y and Z. And that could mean it's left out of the accident report, even though it may be just as much (or even more of a) contributor to the accident than the easily pointed out details from the last paragraph. It's identified not for X moment in time by the accident investigator, but over many flights (or decades of flights) by conscious pilots, instructors, etc., especially when they can see these trends and changes spanning over long periods of time, or over different sectors of the industry, as they observe habits and inclinations.

The thing is, no matter how carefully we cinch up every identified hole in the logic traps and system interactions (i.e., the details) a new unforeseen one is always liable to show itself in the future and be best (or only) curable by a flight crew with a grip on the big picture (i.e., the airplane is going THIS WAY, and I'm simply gonna make it go THAT WAY, with the readiness and ease of an instructor saying "I have the controls" to a pre-solo student)
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Old 15th Oct 2018, 04:20
  #73 (permalink)  
 
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Accident reports are variable in quality, but are generally improving. Very seldom do we see the term 'root cause' used and some investigation agencies have gone away from using the term 'cause' altogether. Accident reports should never apportion blame, so you should never see "the cause of the accident was the pilot doing xxxxx " wriiten. Investigation of human factors is changing for the better too, particularly in the field of human/machine interfaces. I have recently qualified as an accident investigator and the main emphasis on my course was human factors. Based on the premise that people don't go out to do a bad job (if they did then this becomes sabotage and a deliberate act - therefore not an accident), the investigator has to try and understand why an action made sense to the operator at the time. The factors which lead up to an accident are numerous and varied - and never simple. One basic statement such as "The pilot didn't understand the auto-thrust modes" is neither accurate or helpful. You have to look at the reasons why they were misunderstood.

It's a fascinating subject and those who wish to understand this topic more could do no better than to read 'The Field Guide to Understanding Human Error' by Sidney Dekker. It's not an expensive book, and will change your opinion on human actions, and may well change the way you act as an operator yourself. It's a 'must read' for accident investigators.
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Old 15th Oct 2018, 06:38
  #74 (permalink)  
 
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Originally Posted by Vessbot View Post
A big problem is that "the automated systems are more competent than the pilot" is largely a true statement. From what I've seen in general, I would place more stock in the automation saving the pilot, than the other way around.
Are you a flight simmer? You don't come across as someone who really is a pilot
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Old 15th Oct 2018, 08:00
  #75 (permalink)  
 
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Originally Posted by Vessbot View Post
Both the big picture and the details are equally important to focus on. I think accident investigation boards are better at identifying the details, which are more tangible and more easily describable. Such as some logic trap in this or that combination of submodes, or a seldom-encountered interaction of A and B systems... things that can be pointed to and shown that happened in a particular moment on the flight. And these can be (and should be) fixed so as not to contribute in a future accident.

But why the pilot acted or failed to act in a particular way? That's fuzzier and harder to identify. It has to do with trends, habits, and mental states. It's harder to identify as happening at X moment in time and setting off the chain of events Y and Z. And that could mean it's left out of the accident report, even though it may be just as much (or even more of a) contributor to the accident than the easily pointed out details from the last paragraph. It's identified not for X moment in time by the accident investigator, but over many flights (or decades of flights) by conscious pilots, instructors, etc., especially when they can see these trends and changes spanning over long periods of time, or over different sectors of the industry, as they observe habits and inclinations.

The thing is, no matter how carefully we cinch up every identified hole in the logic traps and system interactions (i.e., the details) a new unforeseen one is always liable to show itself in the future and be best (or only) curable by a flight crew with a grip on the big picture (i.e., the airplane is going THIS WAY, and I'm simply gonna make it go THAT WAY, with the readiness and ease of an instructor saying "I have the controls" to a pre-solo student)
Vessbot, I may be wrong, but by reading most of Your posts it does not really seem that You are an active professional pilot otherwise You would -to a certain extent- be familiar with the logics of, to name a few, pilot core competencies, performance indicators, observed behavioural markers and threat & errors management. These are, amongst others, bread and butter for instructors & examiners and definitely a familiar environment for line pilots as well as the core foundation of incident/accident investigations.
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Old 15th Oct 2018, 13:07
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Originally Posted by sonicbum View Post
Vessbot, I may be wrong, but by reading most of Your posts it does not really seem that You are an active professional pilot otherwise You would -to a certain extent- be familiar with the logics of, to name a few, pilot core competencies, performance indicators, observed behavioural markers and threat & errors management. These are, amongst others, bread and butter for instructors & examiners and definitely a familiar environment for line pilots as well as the core foundation of incident/accident investigations.
Maybe we have different experiences in the cockpit, but can you be more specific? Because I don't really know what I'm responding to. What are these things I should be familiar with but my posts are lacking?
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Old 15th Oct 2018, 13:12
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Also had some good fun in the 737 sim watching experienced Airbus, Fokker, MD80 and Dornier pilots try to find the TOGA button on a go around.
And no doubt while stuffing around trying to find which button to press they clean forget to push the bloody throttles open as first action.
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Old 16th Oct 2018, 15:13
  #78 (permalink)  
 
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A37575

Nope
Every single one disconnected the AT (via their old TOGA button)
Shoved the TL up and pulled the stick back so hard the AP let go!
Passenger comfort was temporarily suspended, and I hung on for dear life.

By the time they left my sim ,they were all cured of " The Other Aircraft".
Minus one crew i refused to recommend for test.But that is a story for another day.
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Old 16th Oct 2018, 16:54
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It may be a little thought provoking to think about the issues from the side of the aircraft systems designers. It is very expensive to meet an assurance level at DAL A and also automate the handling of every conceivable circumstance and failure and perhaps create some heuristic approach for failures and circumstances that are not foreseen. So instead, the approach has been for the automatics to 'gracefully' degrade and hand the bag of bolts to the flight crew. The flight crew are expected to be able to manually recover in the degraded/alternate state from any of the potential issues that the automatics cannot. Unfortunately, as instances quoted in this thread attest to, on some occasions the flight crew are not up to picking up the pieces when the aircraft systems peremptorily hand them control and simultaneously enter some degraded mode/alternate law. Indeed, just the complexity of managing the aircraft in its degraded mode/alternate law is sufficiently challenging for some crews.

Then there is the imaginative (mis)use of capabilities that the analysts, software designer and the certification testers did not expect: the systems equivalent of using a fire-extinguisher to hold open a fire door . Users will always do this with systems and they own them, but the capability that they are fulfilling with a particular function was unintended or perhaps being used outside its intended purpose, and consequently can lead to unintended consequences and exhibit 'features' that can/will catch out the unwary.

The crews that the analysts designed for 15 or 20 years ago when the design was finalized are now taking pensions (and commenting on here) and the expected capabilities and awareness of the aircraft are completely different now than they were. A lot more thought needs to be given to the human factors of the systems what was useful in the old days may be an irritant now and vice versa.
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Old 17th Oct 2018, 06:16
  #80 (permalink)  
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It may be a little thought provoking to think about the issues from the side of the aircraft systems designers. It is very expensive to meet an assurance level at DAL A and also automate the handling of every conceivable circumstance and failure and perhaps create some heuristic approach for failures and circumstances that are not foreseen. So instead, the approach has been for the automatics to 'gracefully' degrade and hand the bag of bolts to the flight crew. The flight crew are expected to be able to manually recover in the degraded/alternate state from any of the potential issues that the automatics cannot. Unfortunately, as instances quoted in this thread attest to, on some occasions the flight crew are not up to picking up the pieces when the aircraft systems peremptorily hand them control and simultaneously enter some degraded mode/alternate law. Indeed, just the complexity of managing the aircraft in its degraded mode/alternate law is sufficiently challenging for some crews.


Excellent stuff Ian, best description I have heard. You have made the case for much more 'traditional' flying experience that will allow natural reactions to the unusual to develop before being let loose on an Airbus or similar. Unfortunately the aircraft has been sold as so easy to operate even a 250 hour pilot straight from flight school can fly it and ever cost conscious managements have fallen for it, the AF447 loss simply didn't penetrate the armour of the financially driven, be they a manufacturer, an operator or the flying school.
Old ways are not always bad ways anymore than the new ways are the right ways. Possibly time for the regulators to step in to scrub the Multi Engine Licence and insist on 1500 hours of GA or 1500 hours of mixed GA and light twin turbo first officer experience, anything to develop the natural reactions to an aircraft with the potential to fall out of the sky if not attended to properly?
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