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-   -   ANA Japan roll incident. (https://www.pprune.org/tech-log/463127-ana-japan-roll-incident.html)

UK019 15th Sep 2011 10:12

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.

Callsign Kilo 15th Sep 2011 10:19


The NG is poorly designed when it comes to switches and where they are placed. You ask for the wipers, and you get engine ignition. You ask for eng a-ice, and you get hyd pumps. Try to operate the MCP in darkness/smoke, and you will have a hard time (as another poster already pointed out) to differenciate between heading, alt, etc.

In this tread we have the super pilots who never make mistakes, and think selecting a wrong switch is impossible and due to poor operating procedures. They are in for a big surprise sooner or later.
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:

White Knight 15th Sep 2011 10:25


Originally Posted by cactusbusdrvr
Dani, read the post before you comment on it. The post was about confusing the fuel pumps for the hydraulic pumps, which is very easy to do on an Airbus as they are above each other on the overhead. HYD, FUEL, ELEC, AIR, in descending order.

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:

FlexibleResponse 15th Sep 2011 11:55


White Knight

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
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..?

rubik101 15th Sep 2011 12:10

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.

Yaw String 15th Sep 2011 12:24

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!

UK019 16th Sep 2011 11:40

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.

Dani 16th Sep 2011 13:01


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.
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

40&80 16th Sep 2011 21:22

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.

UK019 17th Sep 2011 09:31

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!

Dani 17th Sep 2011 10:33

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.

poorjohn 28th Sep 2011 20:04

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.

danger85 29th Sep 2011 01:15

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:

lederhosen 29th Sep 2011 06:24

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.

Denti 29th Sep 2011 08:48

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.

punkalouver 29th Sep 2011 16:46


Originally Posted by Lord Spandex Masher (Post 6693016)

It's never been a requirement at the airlines I've worked for to have an extra crew member in the flight deck if one of us is having a quick widdle.

A number two or longer absence, for whatever reason, does require the extra crew member though.

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.

Indarra 29th Sep 2011 23:24

Video recreation:

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

VH-Cheer Up 30th Sep 2011 08:09

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.

NutLoose 30th Sep 2011 11:42

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

&


In a chilling reminder of how a simple human error can override the highest of high technology, an investigation has shown that All Nippon Airways Co. narrowly escaped a catastrophe earlier this month when its plane almost flipped over after a co-pilot hit the wrong button while trying to open the cockpit door for the plane’s captain, returning from the restroom.
The revelation came at an awkward time for the Japanese carrier, just hours after the first of the new-generation Boeing Co. 787 Dreamliner jets on which it has built its future strategy finally landed in Tokyo on Wednesday, more than three years behind schedule.
The celebratory mood was quickly over as Shin Nagase, a senior executive vice president at ANA, apologized and bowed deeply in front of TV cameras at a news conference to apologize for the trouble caused by the incident, which took place Sept. 6.
According to the Japan Transport Safety Board, two flight attendants were slightly hurt when the Boeing 737-700, with 117 people aboard, tipped more than 130 degrees to the left at one point and dived about 1,900 meters in 30 seconds during a flight from Naha on the southern island of Okinawa to Tokyo. Two flight attendants were slightly injured and six passengers became airsick or reported neck pains.

finfly1 30th Sep 2011 11:52

What dashboard 'button' would cause such a reaction?


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