We too have the CCTV but it doesn't cover this: Pilot goes for a pee. Other pilot becomes incapacitated. Door entry system fails and we have an operational pilot in the cabin with the pax and unable to get back to the flight deck. End of aeroplane and everyone in it. Sure, it's a long-shot - but not impossible. That's why my Company always has two people on the flight deck in flight. It's usually a cabin crew member but if there's a third pilot, that fulfils the requirement. It's a simple, easy, safe procedure and costs nothing.

There is no such thing as super pilots who never make mistakes. Yes the NG is based on an antiquated design, however I'm a firm believer in LOOK before you TOUCH. People seem to believe in doing things in a flash of light - where's the rush? This is my observation anyway; and I see it quite frequently. The PMs hand moves like a world wind. A scarce glance is made in it's direction -
bam; system B is depressurised or in this case a passenger airliner approaches a spiral dive. Either people start to look or we adjust the retirement age to directly correlate with the onset of bladder issues! :ok:

Except the HYD switches are guarded and the FUEL not........ Bit of a difference methinks.

At least that's how it is on 330/340:ok:

White Knight,

The HYD switches only became guarded after SQ managed to switched off all four HYD switches in the cruise. Now, that was exciting...

Perhaps the "bit of a difference" is not as large as one may think when one reflects in the cool light of day..?

I'm not sure if UK019 is in the same company but the system is the same for us and it works. Peeing pilot is replaced by an F/A. Flirting-chit chat goes on for a few minutes. Peeing pilot returns, knocks or buzzes, non pee pilot checks the camera or the F/A peeps through the peep hole and opens the door. Body contact sometimes occurs and everyone is happy. No risk, no cost, no altitude lost, no switches operated.

Not sure the SIA incident involved the Cpt...Anyway, am pretty certain the full crew complement were not on the flightdeck while the "Fuel balancing" was attempted..
Does not matter what age or experience you have...the only thing you can be certain of finding with your eyes closed is...well...you know what:mad::E...Sorry ladies!

Rubik101, having read your public profile (I want your lifestyle please) no I don't think we are in the same outfit, but what you say makes total sense and as you say, it works - with a bit of ''frottage' to boot! ;) On a serious point though there are no negatives in having a rule that says that the flight deck must never be occupied by just one person.

That's then about a tripple or quadruple failure. Door system has a fail safe mode, and if you know the code you can access from outside. If that's still not working, there is a general code and an emergency code. If you loose your captain (due to bladder leak) and you loose your FO and you loose all your electricity or the whole door mechanism - well that's less probable than an all engine failure I would say.

People always invent so complex failure when dealing with new systems. Come on - you can do better!

Dani

Hope the health and safety people are not reading this.
They would stop 50 ton trucks operating with one crew around the country and also a Mum doing the school run without a responsible adult also in the car..probably not be allowed to operate your ride on lawn mower single driver.

Dani no it isn't. It's a double failure (the door and the incapacitation)

A double system failure is something I have experienced twice in my career (33 years airlines, 10 before that flying elsewhere in aviation) one of which caused a high speed rejected T/O when two utterly unrelated systems failed at precisely the same moment. No-one (including me) could believe it, but the evidence was there in front of our eyes.

As I said in my post, it's a long-shot, but the prevention is so simple and has no cost that I'll stick with it if I may. I don't have a choice anyway - it's SOP in my outfit!

The door doesn't fail per se. You have an electronical, an electrical and a mechanical component. If all three fail it's a tripple fail alone (without the dead FO). Experience show (Helios B737) that one is able to get inside if you really have to and if you are not a terrorist and if you get help from the cabin side.

Interesting that a subsequent thread got locked for some reason, while debating the meaning of an initial analysis that purports to show that the aircraft "inclined to the left a maximum of 131.7 degrees". "2.6G" was mentioned, too.

Is there a new feature being rolled out on Boeings enabling reverse flight? According to the Sydney Morning Herald in Australia, "Images from the flight recorder on the Boeing 737-700 showed the plane veered to the right and then sharply to the left, before dropping backwards.":ugh:

This is very similar to the recent incident in India where the co-pilot pushed the column unintentionally and was unable to understand what was going on when the aircraft went into a dive.

It also raises the question what the co-pilot was looking at when he twisted the rudder trim. It looks completely different and is in a different place from the door unlock. If he was looking at the instruments how come he did not see the control wheel moving way out to the side?

Above all it raises the point that most pilots have little experience of manual flying these days and when an unusual attitude develops they are initially stumped. Our sim training exercises lack the surprise factor which seems to have been the problem here.

The door unlock can be pretty much anywhere and we have at least 10 different locations in our fleet, at least one of them where it is directly adjacent to the rudder trim. Added to that there are some very bad CCTV setups around as well, for example having the screen on the aft overhead panel behind the left seat. An FO would have to lean out of his seat over the center pedestal to see anything on that, identify the person who wants to enter the flightdeck, keep observing the area why he supposedly opens the door. In that position he would neither see the flight controls and displays nor the door unlock button or rudder trim.

Still, both knops have a different design, but the mode of operation is the same.

Newer CCTV setups display the picture on the lower DU, much more convenient.

Boeing approved retrofits or even boeing designs can be ergonomic nightmares, and the whole door thing is just that in some configurations.

It is on the aircraft I have flown in recent years where there is no keypad to be able to get back in the flight deck. F/A required in flightdeck when one crewmwmber leaves the flight deck.

Video recreation:

http://www.yomiuri.co.jp/stream/m_news/vn110928_6.htm

Ah, the old "cockpit door/accidental roll" knob confusion problem...

Cabin PA: "And now, ladies and gentleman, a display of aerobatics by the first officer. Please ensure your seat belt is firmly fastened and your tray table is in the upright position".

Origato, gozeimas.

Japanese ANA 737 Almost rolls inverted
 

See

Wrong Button Sends ANA Jet Nearly Upside Down - Japan Real Time - WSJ

CGI Film of the incident is interesting

&

What dashboard 'button' would cause such a reaction?

According to the article

Rudder trim issue according to Flight Global:

VIDEO: ANA 737 rolled near-inverted after rudder trim blunder

You have to be careful that when you attempt to fix one problem that you don't generate a load more.

The locked door policy was introduced to prevent unfriendly people easily gaining access to the flightdeck post 9/11.

Trouble is crewmembers now have to go through all this rigmarole just for a comfort break - it's not the first time that the rudder trim has inadvertently been used in this manner.

It's all about risk management and personally I feel the locked door policy carried extra risks.

Just an ATCO so excuse me if I'm asking stupid questions, BUT.

Why would you have a button which if inadvertently flicked inverts the airplane?

This button adjusts my range... this button the brightness and this one blows up the building... yeah.

Recovery? What recovery? Instincts? Who is kidding who? What else do you expect from pilots who might have 100 hours total time of hand flying when they retire. Much worse is on the horizon I assure you.

Couple the lack of ability with a sense of entitlement and bravado (on the ground and safely ensconced in the bar with his mates) that needs to be seen to be believed, et voilà, you have airliners rolling over on their backs.

If you haven't been in the cockpit with these guys you don't and can't understand. Once you have, it is all made clear.

Where in hell are the insurance companies and ICAO? Forget the so-called unions, management, and complicit regulatory agencies staffed with former company hacks. Don't believe me if you choose, but it all happens to be true.

I await my mandatory tongue lashing for pointing out the obvious.

The rudder trim is a round dial on the central pedestal. It is not in your direct line of sight unless you purposefully turn around and look at it.

The dial is of the continuous type. Meaning if you turn the dial to starboard the rudder will incrementally trim farther and farther into starboard.

Coincidentally the button to release the locking mechanism of the door is also a dial. It is positioned quite close to the rudder trim dial. Both dials are not in sight of a pilot who has not turned around to look at them.

In practice flight attendants will often call the cockpit to take orders for food or drinks. Sometimes people add last minute things over the flight inter-phone so the flight attendant takes a bit longer than usual to enter the cockpit. Some pilots, especially FO's are vulnerable to this, grab the wrong dial and hold it to the left. If an FO is busy reading, talking to ATC or something else he might inadvertently grab the rudder dial instead of the door dial. Because they are behind him and relatively close to his seat he won't notice this in his peripheral vision.

Holding the door dial to the left unlocks the door mechanism. You need to keep it turned to the left actively to keep the door unlocked for the flight attendant to enter the cockpit.

As you can see from the video the 737 was tipping over to port side. This coincides with my description of the operating principles above.

edit: Oddly enough: even though the dial itself is not visible to the pilot, the displacement of the yoke should be obvious almost immediately. The AP will attempt to balance the increasing out of trim position by applying opposite aileron. This becomes very clearly visible once it goes over a few degrees as the entire yoke would be turning farther to starboard as time goes by.

It takes 29 seconds to hold the rudder trim in the 737 full over to obtain full trim from neutral. It is hard to believe that even the most incompetent pilot would hold the switch that long in mistaken belief it was a door unlocking button. Even if he operated the aileron trim by mistake it would take about half as long to obtain full aileron trim and that includes pressing two switches together. Something not quite right here. Another case of the automatic monkey syndrome where lack of basic manual flying skills is practically non-existent in many airlines.

Unfortunately the lack of manual flying skills is very existent ...

Just a question for the professionals -- The information provided suggests that the plane rolled significantly in excess of 90 degrees, yet the FO was able recover it to stable flight. Does that not suggest that this FO had some pretty good situational awareness and manual (aerobatic, indeed) flying skills? Or would this recovery have been automatic?

PS: it also seems to suggest that the 737 retains a lot of the aerobatic capability (without being torn apart) that Tex Johnson demonstrated in the Dash-80 (707 precursor).

I tend to disagree here.

29 seconds is not a very long time. Very often the attendant or other pilot calls to gain access but takes some time to actually open the door. I've seen this happen quite a few times already. People just hold the switch to the left and keep it there until the other person actually opens the door.

I'm not sure why you are talking about aileron trim.

Pilot calls to re-enter cockpit. The one on deck reaches over to turn the unlock knob. The one outside jiggles the door. Still locked, calls again (now a bit pissed). The one inside thinks to himself (while still holding the wrong control), "Dumbass. Can't even operate a doorknob." I can see 29 seconds passing with such antics.

Yup, 29 seconds is no all that much. And the control column displacement is not necessarily within primary field of view if the FO is trying to see something on that tiny CTTV screen on the left aft overhead panel (which means he is hanging out of his seat halfway across the center pedestal staring behind and to the left side) where he has to continuously check to make sure the area in front of the flight deck door is clear.

By the way, he didn't use full left rudder trim, it was just two left trim inputs each lasting a pretty short time, that was all it took. Check out the first report which is sadly in japanese but clearly shows some of the FDR data as well as the flightpath and center pedestal of this configuration.

For someone with supposedly no manual flying skills he did a pretty fast recovery though, during night without anticipating any upset. Not bad on that at all, while of course the initial action wasn't great but not all that surprising in that 40 years old flight deck, designed without much knowledge about ergonomic man-machine interfaces.

Wouldn't have happened on an Airbus. Ground the Boeing !!!

I'm at risk of sounding like Mr Angry here, but I am reading a lot of excuses for some pretty rubbish piloting skills.
Most of the controls on that panel are within 10cm of the rudder trim. The two controls in question are a different size and shape.
If you haven't a clue where the switches are by feel, go sit in the cockpit for hours and practice the muscle memory.
If you don't know where the switches are, look. It's not as if he was doing night AAR or anything busy.
If he wasn't looking at the panel, then why wasn't he looking at the instruments?
29 seconds IS a long time.
Coupled with AF447, I would love to know why incompetence of this level isn't being spotted earlier (e.g. in the sim)

I for one I'm not too quick to crucify, not going to get into a deep discussion of security sensitive procedures but it is not uncommon to be holding that switch for a while because your partner turn around to answer a question from the CA, it only takes a few seconds of being distracted not to notice that the ailerons are deflecting in the opposite direction to compensate until the AP gives up and then all of a sudden he found himself in an almost hard over rudder situation, single pilot, without enough tolerance in a specific orifice to put a needle trough and this didn't turn into a smoking hole on the ground, we all know that some rudder events weren't that lucky and this was with two pilots working the problem. It is not that I am not critical of the event, I'm just looking at it from the perspective that this paid hobby of ours teaches very heavy handed lessons.

Next time you are doing recurrent, most of the times one finishes early right? tell the checker running the sim to climb you to 350 and then while you are turned looking at the back of the sim, do the same thing, operate the rudder trim until the A/P disconnects, I know it is not a true test because you are expecting it and he wasn't, but it will give you an interesting perspective as to how easy this could have ended in tragedy.

I tried it in the sim yesterday. Shocking how easy it is to get in an upset like that.
BTW, a few posts back there is a photo of a 737 pedestal. Our pedestal is built up in such a way that the door knob and the rudder trim are directly next to each other.

Just a reminder (for "fin fly" and "short approach" and others):

The 737 (like most multi-engine planes) has a very powerful rudder for yaw control with an engine failure, which can indeed turn a plane upside down and (via the inverted lift) point the nose at the ground very rapidly if activated unexpectedly.

Search the Web for "United 585" and "US Air 427" to find two fatal 737 crashes caused by a rapid roll brought on by uncommanded rudder deflection (in those cases, a mechanical glitch, rather than reaching for the wrong knob).

The low-tech solution posted earlier on another thread is still relevant so I apologise only to those who have already seen it.
Pilot wishing to leave the flight deck calls the FAs and waits until one appears at the cockpit door, enters the code and is allowed into the flight-deck. Pilot leaves and door is locked behind him.
Pee and chat take place for a few minutes until the pilot enters the code and the FA looks through the peep hole and the seated pilot confirms via camera, if fitted, that it is indeed the pilot outside the door. Now the safe part, the FA opens the door by using the door handle!
Result, no stupid switch position will ever catch you out again.
Cost; zilch.

i believe there's definately more to this..... hopefully they come out with a full investigation and report.

normally, if you flick the switch and open the cockpit door, after a while.. if the other crew member doesn't come in, would you keep holding it? or let it go? i would let it go and check the camera to see what is he doing.

i don't know bout the 737s... i fly the A320.. and when i flick the open door switch, i'll hear a loud "Tack" indicating that the door strikers are unlocked.

I flew the -200 & -300 and all we had was a push button to lock/unlock the cabin door. WHEN did they change this switch and WHY ?!?!