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

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.

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 !!

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?


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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.

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) :).

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.

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.

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?


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

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.

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.

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?

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?????

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.

>>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.

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 ?

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.

But then how would you listen to the ball game?

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?

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


All I can say is that you have never flown into LHR or LGW at peak hours. What is easier to recall, 132.475 or 3247?

And the proof of the pudding is the number of missed frequency changes, especially while in 'foreign' regions. I count about six or ten missed frequencies every day. Thats six or ten opportunities for extra ATC stress and a potential incident. And for what reason? Because some desk-jockey has only half a brain and did not ask users what they want.

Besides, when you are on a very busy frequency, with no room to get a word in edgeways, what is simpler and shorter to say - 132decimal475 or 3247 ?? So ATC are struggling to control the numbers of aircraft in thier sector, because of unwieldy phraseology. KISS wins every time, while complexity leads to incidents and accidents.

I've just timed myself saying both of your examples. 1.0 second for the long one. 0.8 seconds for the short one.

Not exactly a life saving difference.

Both are just as easy to recall, for me anyway, having just heard them.

Funny you should mention those airports. I've been based at both, at separate times, for a total of 15 years.

Nothing to do with GPS, however i suggest you check FCTM page 5.39 (Raw Data Monitoring Requirements). Raw data monitoring is recommended but not required both for classics (EFIS update 7.2 and FMC version > 7.1) and NGs. The MEL allows dispatch with the ADF inop as long as one FMC is operative even for NDB approaches.

Sorry, but you cannot do an ADF approach without an operating NDB and ADF - period !

If you do not have a ground station and the appropriate cockpit instrument, you are doing an RNAV FMC approach, not an ADF approach. And we have no RNAV approach plates in our Euro-Jepps, and so I'm presuming that RNAV (FMC/GPS) approaches are not yet certified to any of the airfields we visit.

Your reference in the 737 FCTM is referring to whether "raw data" or "map display" is selected - not whether the ADF is working or not. In other words, you can use map display mode, if you have overlaid VOR or ADF pointers for cross-checking (which many systems can do) or you flip between raw data and map display to check that the map is in the right position.

Note the note at the bottom of this section: - "Compare VOR and ADF systems to detect possible map shifts". You cannot do a map cross-check, if the VOR or ADF is u/s or not fitted !!


This is what happens, when people use a (map-shifted) RNAV FMC approach, instead of the raw NDB/ADF.
1996 Croatia USAF CT-43 crash - Wikipedia, the free encyclopedia


Ditto the B-Med Airbus going into Addis Abeba. The FMC plot and terrain display were off by some 3 miles, leading to a go-around just 60 ft over the high terrain. Now while the VOR would give occasional signals of its unreliability (the VOR was the primary fault), the FMC gave no indication that it had a map-shift. This was the biggest complaint in the report, that the FMC knew it was getting bum VOR information, and therefore may have a map-shift, but did not bother to tell the pilots. And the pilots could not check for a map-shift, because they were comparing bum data with bum data.
Report: British Mediterranean A320 at Addis Abeba on Mar 31st 2003, wet VOR nearly causes two CFITs

Incidentally, the New Scientist report on this indicated the crew were highly influenced by the terrain display, which showed them passing nicely through the valley. However, the terrain display was likewise mapshifted. Not sure where this info came from, because the AAIB report underplays this aspect (that the crew were merely following the FMC and terrain plot, and disregarding the raw VOR signal).

One would have thought that following an erroneous and displaced VOR radial would bring you eventually to the VOR, whereas this flight paralleled the VOR inbound, which is what would happen if you followed an erroneous FMC position.

Search Results - page 1 - New Scientist



And I am not even sure that GPS-RNAV is entirely a solution at present (as was recommended in the B-Med report). It works well with high accuracy and reliability, but Europe is still concerned that the US may degrade GPS signals or switch the system off during periods of international tension. This is the primary reason for Europe developing and launching the Galileo GPS system. When that is up and running, and there is full confidence that erroneous signals can be detected and warnings given, then Europe may proceed to RNAV approaches.

Slight exaggeration maybe?

Operation of the rudder trim does not give full rudder deflection. The two accidents you mentioned were thought to have been caused by full un-commanded deflection of the rudder but in the reverse sense to the movement of the rudder pedals. Very few pilots could have recovered successfully in the limited time at their disposal in both those events.

But even with full rudder trim deflection applied inadvertently, the 737 in the ANA incident would never have got to the extreme attitude that happened without some crazy manual flying inputs by the pilot.

have i missed something?
 

i've read as many of the replies as i could and though i have seen it implied, would i be out of line to say in simple terms, this was the work of a complete idiot, jobsworth, waste of space pilot?

yes, we have all touched the wrong switch and have pushed the wrong button but if we are simply paying attention to the present situation, we see the wrong result and make a correction right away. but to hold any knob, switch, handle regardless of the shape for such a length of time and not notice the aircraft beginning to roll over is the work of a total idiot.

can't blame the airplane for this one!

I think you negate the role of the autopilot.

During the two left rudder-trim inputs, the autopilot will have been counteracting with aileron - hence the slight opposite right roll to start with. Then the autopilot will go out of limits and disconnect, and so the resulting uncorrected roll rate to the left may well be quite dramatic.

Exactly as SS says - I know of one previous incident caused by mis-management of fuel balancing where the bank angle exceeded 90 degrees on A/P disconnect.

New captain at big airways and he was over the alps at the time iirc!

Because he thought that this is the door knob: suspected train of thought: "Ah captain wants back in. Lets open the door - uh oh, something is wrong - why is the captain not coming, help! Lets kick the button a bit more so he finally gets into the cockpit - uh oh, its getting worse - c'mone door, open.. (Keeps on turbning the button frantically..."

You can't be serious.

Well, maybe you are...I recall some of your previous posts.

I can understand what has happened, the FO would have activated the rudder trim and would have then been distracted by looking at the aircraft deviating away from normal. That initial confusion was no doubt replaced by panic when the aircraft had a serious 'upset'. It would have been when action was taken to recover the aircraft that he actually 'released' the trim. No doubt had was frozen on there whilst brain tried to process what the hell was going on. I think some recognition could be given to him for actually recovering the aircraft back to 'normal' with out further 'upset'. We have already seen several times in recent history that in these situations a bit of mishandling in 'upset' situations can lead to the loss of the aircraft. Yes he co*ked up getting into the situation but thank god had enough basic handling skills to recover from it. These basic skills are what seems to be lacking in certain areas.

Think again. He already has caused a major upset (unusual attitude) by putting the aircraft into an almost inverted nose down situation of his own making. . And does this therefore prove he had enough basic handling skills in the first place? I don't believe that for one minute. He then eventually gets the aircraft right way up. I would say that was the result of pure bloody good luck - not good basic handling skills. The facts will eventually be published although maybe kept in-house. The guy has a pilots licence but that's about all.

Found the following on a website blog. Does the 737-700 AP have a CWS function?
Re the ANA 737-700 incident. There is not much to go on because only media reports are available at present. So who did what to which is unclear. Maybe when the F/O hit the wrong switch (he got the rudder trim rotary knob) the door didn't click open or whatever the door is supposed to do to unlock. Someone mentioned earlier it takes 29 seconds for the rudder trim to move from centre to full scale left or right.

The ANA incident happened at night. This is significant as we shall see. Assume the F/O held on full rudder trim maybe not for 29 seconds but a significant amount of time. Eventually the autopilot either went into CWS roll as the control wheel turned to maintain the present heading - or the autopilot disconnected altogether causing the aircraft to roll. It maybe the first officer then lost control when he tried to hand fly at high altitude at night in IMC on instruments. Most of his 737 flying would have been on full automatics from shortly after lift- off to shortly before touch-down.

Another possibility is if the CWS roll did remain in place (in other words it had not yet disengaged itself) and the unusual position of the control wheel alerted the F/O to something going wrong. If he then tried to correct to wings level too harshly with CWS roll engaged it may have caused the autopilot to disconnect in the roll mode and pilot confusion with hand flying (lack of instrument flying skills) could eventually lead to an upset.

Or if the F/O inadvertently hit the stab trim switch on his control column at any stage while the AP was engaged in any mode, the AP will disengage in all axis leaving the F/O to hand fly and he probably did not have the ability to do so. It may have been a different story in day VMC but to have a typical F/O steeped to use automatics throughout his career on the 737, then a IMC recovery is going to be a real problem.

Am I missing something ?

Some FDR traces are available on the PDF by the japan agency.
The duration of the rudder trim inputs are shown on those traces.

Why do people still elaborate theories about "29 seconds, what a fool to keep that for so long", when the traces show 2 inputs, each one with a duration of ~5-7"

29 seconds is the time it takes to go from trim neutral to full trim. Nowhere was it said that in ANA's story the knob was held for 29 seconds!!

Thread drift,

Lord SM, if you've done some human factors in terms of short term memory you should know that the magic number is 7.

One, two, three, decimal two, seven, five uses it all and doesn't leave space for heading, speed and/or altitude changes to be included.

Also the fact you've done 15 yrs around London doesn't mean everyone has, some of us fly in Europe less than once a month.

The brain also uses chunking in short term memory such as twos (1,2) threes (3,4,5) and fours (5,6,7,8).

132.475, two chunks 3247 one, leaving more short term memory for HDG / SPD & ALT in the same instruction.

Now lets talk about fatigue ...............

On a point of pedantry, one doesn't pronounce the 3rd decimal place. Thus, your frequency should be pronounced "One, two, three, decimal two seven" (leaving apart, that it, the pronunciation of "tree, fife" etc :)

Of course not, but pilots just love to talk out of body cavities that weren't meant to talk out of

@Pontius: check your knowledge of the relevant R/T procedures:

No answer, Denti, about this novel idea of doing ADF approaches without an ADF?? !!

I presume you are a training captain with a well-known low standards airline. They were mostly crap instructors.

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