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

Hotel Tango 8th Sep 2011 13:28

ANA Japan roll incident.
 
Courtesy of the Aviation Herald:

An All Nippon Airways Boeing 737-700, registration JA16AN performing flight NH-140 from Okinawa to Tokyo Haneda (Japan) with 117 people on board, was enroute at FL410 about 23nm south of Hamamatsu (Japan) when the aircraft violently rolled left causing injuries to two flight attendants and descended by about 6000 feet levelling off at FL350 again. The flight continued to Tokyo's Haneda Airport for a safe landing. The two injured flight attendants were delivered to a hospital with flesh wounds.

The airline reported, that the captain (64, 16,000 hours total experience) had taken a toilet break and was about to return to the cockpit requiring the first officer (38, 2400 hours total experience) to open the cockpit door. The switch to open the cockpit door is located about 10 centimeters/ 4 inches away from the rudder trim switch. By mistake the first officer operated the rudder trim switch instead of the door opening switch causing the aircraft to violently roll left and descend by about 6000 feet before the first officer was able to return the aircraft to stable level flight. The captain subsequently entered the cockpit. Two cabin crew received minor injuries (flesh wounds), no other injuries occurred. There was no turbulence in the area at the time of the occurrence.

Japan's Transportation Safety Board rated the occurrence a serious incident, opened an investigation and dispatched three investigators on site.

Henri737 8th Sep 2011 14:01

This is not the first time this occurance took place. I know of a similar incident. It's all about ergonomics on the 737: look at the B-hydraulic vs engine anti-ice switches..... Time for a panel redesign.

tezzer 8th Sep 2011 14:04

Just been reported on the BBC Radio news bulletin.

Wonder if there was a requirement for another "toilet break" soon after !

westhawk 8th Sep 2011 14:36

It's not just 737s either. In fact you probably couldn't name an airplane where something similar isn't possible or hasn't been done by someone somewhere at some time. Those old autopilot and yaw damper "paddle" switches located adjacent to each other on '70s and '80s era Collins A/P controllers? Many a PF who called for the Y/D on at 400' surprised by the suddenly engaged A/P that doesn't want to go the same direction as the pilot does. Fire bottle switches? I got plenty of work replacing discharged fire bottles when I was a mechanic. Ever throw the wrong switch during an abnormal drill in the sim? Yep, been there and done that too! (a better place to learn such a lesson than in the plane)

Some pilots (and mechanics) learn early on that you really must stop and think before flipping a switch, no matter how mundane the task might seem. Some learn later than others.

Oops indeed!

But the point that better thought out ergonomics can reduce errors in this area is well taken.

hetfield 8th Sep 2011 14:48

Thx God it wasn't an A300.

glad rag 8th Sep 2011 14:54

Lucky the fin stayed on >:getmycoat:<:rolleyes:

HeadingSouth 8th Sep 2011 15:18

in "my" cockpit there are numerous switches in close vicinity of about 4in / 10cm of each other. how about other issues such as concentration, fatigue, other ideas ?

Dani 8th Sep 2011 16:16

If it would have happened in an Airbus, most of the posting would be about "protections" and FBW induced incidents.
In a conventional aircraft its all about "it happens everywhere". I'm sure this will not happen in an Airbus.

westhawk 8th Sep 2011 16:29


In a conventional aircraft its all about "it happens everywhere". I'm sure this will not happen in an Airbus.
"It" can happen anytime someone changes a switch position without first making sure that the correct switch is being operated. I doubt that Airbus or any other type of aircraft are exempt. Why would anyone want to bring the A versus B argument to a thread that applies to ALL machines?

Northbeach 8th Sep 2011 16:56

Spot on
 

It's all about ergonomics on the 737: look at the B-hydraulic vs engine anti-ice switches..... Time for a panel redesign.




I have been on the NG for several years now, I like the jet and it does many things well. However the ergonomics and flight deck design disappoint me terribly. For example, on the flight control panel the heading, altitude and airspeed knobs all feel virtually the same. Now I do not have an engineering or human factors undergraduate or advanced degree(s), but why in the world would the experienced aeronautical engineers with the resources and experience that Boeing has overlook this obvious design weakness?

On the MD-80 (McDonald Douglas product) when one reached for the heading knob there was a distinctive feel associated with the knob because each heavily used input knob had enough of a distinguishing structural design to communicate identification information through touch alone. For example, if I were looking out the side window scanning for traffic and simultaneously reached for the heading knob to comply with ATC’s turning instruction, and if in error, I grabbed the altitude setting knob I would get an immediate “wrong action” feedback through my fingers. Granted this touch based knowledge had to be gained through time on the jet, but it developed rather quickly (in my opinion).

To my disappointment this is not so on Boeing’s NG product; the airspeed, heading and altitude knobs on the flight guidance panel all look similar and, more importantly, are virtually indistinguishable from one another using touch alone. Bad design, really bad design especially coming from a company that has been producing aircraft as long as Boeing has.

As far as getting a design makeover, needed - I agree completely, but doubt it will ever happen. The aircraft was certified as it operates today, to totally redesign the flight deck instrumentation and positioning would require the jet to go through the regulatory recertification process. Boeing isn’t going to voluntarily pay for that. They have enough going on trying to get their new baby, 787, out of the production storage facility and operational.

More on topic I suspect positioning of the flight deck door opening switch is left up to the individual company as “ours” are not anywhere near the rudder or aileron trim switches. People are going to make mistakes, this time the jet fell out of the sky, and fortunately it was recovered. I suspect that pilot will not make the same mistake ever again-one would hope so.


Why would anyone want to bring the A versus B argument to a thread that applies to ALL machines?


Some people must exercise their demons; whether they suffer the lasting effects of perceived or very real insults, inferiority complexes, need to establish their own superiority by putting others in their place or driven by a strong sense of national or regional pride. In those cases every accident thread, and many other threads become a place for them to make the same A versus B arguments. Emotionally they seem to have a need to be on the, and identify with the "winning side" and vindicate themselves as if they personally were responsible for the favorable outcome. I find them tedious reading and tend to skip over the comment(s). When the only tool you have is a hammer, then every problem becomes a nail. So one reads the same dribble over and over again.

I believe Airbus has been winning the larger number of future sales and delivering more jets for several years now. And the A380 seems to be popular. The “marketplace” has spoken. Personally I think the competition is good for the industry as it drives innovation and productivity. Look over our collective shoulders and we will see that the Chinese are working hard on developing their own aerospace design and manufacturing industry. A, B and now C .........

No insult intended to the Canadians, Brazilians, Russians, the Spanish or others by not previously mentioning them. They make fine airplanes that compete successfully in the global marketplace.

westhawk 8th Sep 2011 16:57


I've flown 737 100-800 and they all had a ROTARY KNOB for the rudder trim-- I think the reporter has confused things with the aileron trim (KNOB on the 100/200 and switches from the 300 onwards.)
Same setup for the Lear 60. In fact it's two knobs one atop the other on coaxial shafts which must be activated simultaneously to cause trim tab movement. Apparently either Learjet or the FAA felt the extra protection against inadvertent rudder trim operation was needed. They are spring loaded rotary switches that return to the center (neutral) position when released.

Denti 8th Sep 2011 18:38

@Northbeach, there are at least two different MCP versions on the 737NG, one does have different knobs with different haptic feedback (they feel a lot different), the other brand's knobs are not that much different (there is still some difference). The first one is the old Honeywell panel and the latter one the newer Rockwell Collins one.

@OK456, it might depend on the door system installed, on our 737s the door lock switch is a rotary switch which does not have a push action to normally unlock the door. Its position on the center pedestal changes between aircrafts so muscle memory could well lead you to the wrong position. However the switch is very differently designed compared to the rudder trim.

iwrbf 8th Sep 2011 19:17

this reminds me of a thread some time ago:

http://www.pprune.org/biz-jets-ag-fl...-shutdown.html

I guess the "double check before you change something" is not as old fashioned as the machine-to-human-interface groupies try to postulate on and on and on and on... similar knobs are as bad as knobs that were thrown around a panel in a randomized modern art way but the machine-to-human interface won't EVER be perfect.

Poor FAs (and poor PAX frightened to hell), but happily they all survived... this time...

Sky Wave 8th Sep 2011 19:22


I've flown 737 100-800 and they all had a ROTARY KNOB for the rudder trim-- I think the reporter has confused things with the aileron trim (KNOB on the 100/200 and switches from the 300 onwards.)
The 737-700 that I flew had a rotary knob for the cockpit door control and it was very close to the rotary control for rudder trim.

SW

Dani 9th Sep 2011 04:50


"It" can happen anytime someone changes a switch position without first making sure that the correct switch is being operated. I doubt that Airbus or any other type of aircraft are exempt. Why would anyone want to bring the A versus B argument to a thread that applies to ALL machines?
Because it cannot happen in an Airbus. Airbus don't have trim switches (well, there is one). The ergonomics of a modern airliner is a very important safety feature. Airbusses have so few switches in the cockpit that you would really have to make an effort to mistaken one for the other.

westhawk 9th Sep 2011 04:54


Because it cannot happen in an Airbus.
Well I guess that's the answer then.

Burger Thing 9th Sep 2011 05:03


Originally Posted by Dani
Airbusses have so few switches in the cockpit that you would really have to make an effort to mistaken one for the other.

Apart from the light switches. They are a complete disaster. :}

cwatters 9th Sep 2011 08:30

6000ft sound a lot.

CDRW 9th Sep 2011 14:11

Oh Dani Dani - you never heard about the SIA Airbus en-route over Australia, when the captain decided to turn off some fuel pumps, but turned off some hydraulic pumps. It did some pretty interesting things until normal hydraulic power was resumed. "It would not happen on an Airbus" - yea sure.

Callsign Kilo 9th Sep 2011 14:58

I'm sorry, but what happened to actually using your eyesight to identify the difference between the two knobs? Yes they are close to each other but one is notably larger. It is also in the centre rear of the console with a big black line running through it. Boeing intuitively marked this with large white italics. The word "R U D D E R", or something like that, are labelled on it. This guy also had 2400hrs of experience. Albeit it doesn't tell us how much 737 time he or she has, I kinda presume that they have some level of gumption? Plus he or she must have really deflected that rudder trim knob. It takes some time and I imagine quite a lot of deflection would be required in order to make the aircraft want to perform aerobatics. There is also a notable difference between the way the two switches behave. The door unlock switch has a notable and immediate stop on it. I'm sorry, but I just don't get this one. Neither do I put it down to poor ergonomics. Probably more to do with not bloody looking!


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