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.

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.

Just been reported on the BBC Radio news bulletin.

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

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.

Thx God it wasn't an A300.

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

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 ?

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.

"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?

Spot on
 

Quote:

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

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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.



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.

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.

@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.

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...

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

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.

Well I guess that's the answer then.

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

6000ft sound a lot.

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.

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!

so only 10 cm apart !!!

then we all should be very carefull next time when eating,
and using our fingers, forks or chopsticks...especially in dark cockpit

NOT to mix up the mouth for an eye

OK, poor switch position is fine, but why on earth was there not a F/A on the flightdeck during the restroom break? With the threat of the badguys entering the flightdeck just flipping the door unlock switch on does not sound like the brightest thing in the world to do. one of the inflight crew should have been on the flightdeck ready to open the door after verification.

that's what I call "an effort". ;)

Last time I looked at, the trim switches are not on the overhead panels. So no, you cannot confuse secondary flight control systems with a door lock mechanism in an Airbus (unless you make an effort...).

Of course you could confuse your captains seat with the one of the toilet - the possibilities are endless. What did you want to tell me? :suspect:

Years ago a Deltoid captain climbing out of LAX thought he was turning off the EEC switches on a 767 and somehow turned off the nearby fuel control switches instead. They got the motors restarted 600 feet off the water, got salt spray on the plane and continued on to CVG, RAT extended, with the blessing of ATL flight ops:

ASN Aircraft accident Boeing 767-232 N103DA Los Angeles International Airport, CA (LAX)

The FAA did an emergency license revocation and actually went to his house to pick up his ticket in person. I'm told he took early retirement.

The EEC switches were later relocated to the overhead well away from the fuel cutoffs.

The 737 is redesigned from 727 (I am experienced on both).
That's why 737 ergonomics is just poor.

With reference to the first post, it could not happen on the airbus as the rudder trim switch is inoperative when the autopilot is engaged.

Airmanship...
 

All of us can do mistakes.

But some of our new copilots are more chicken than eagle....:ouch:

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.

So airlines the world over should re-write their SOP's to match your door opening procedures?

We have never required an F/A to come in during a comfort break, nor do most airlines who's procedures I know.

Should we remove our video camera's from our cockpit door?

There's more than 1 way to crack an egg.

US carriers require a FA in the cockpit to verify our security procedures are followed. It seems your procedures use a security camera which would accomplish the same thing. Keep doing what you are doing. We will catch up.

Ten years ago today is when we had to implement these procedures so we probably do a bit of overkill to make sure it can't happen again. I am sure today the bastards will test us again on the anniversary.

Said with a heavy sigh: "IN Japan.........!":(

It is JCAB reg for all airlines that if one crew leaves then a CA (in some companies at least it MUST be the CManager only) comes in to open the door for the return of the crew; I believe this was done although not clearly stated, IF for some reason it was NOT done then one can expect blood!

Also from JCAB a continuous outside watch is paramount to safety - so if the F/O was maybe low experienced and impressionable he could not spare a glance inside the cockpit, far better to fumble around and get it....wrong. :ugh:

If procedures were followed and there was a CA in the cockpit the question of why the F/O was stuffing around with the door lock rather than allowing the CA to ID the returning crew after a pre-arranged signal and open the door will be a point of interest.

As a final - don't know procedures around the world but do know Australia changed 10-15 years ago so that oxygen only had to be worn above 41,000ft
(or something like that) when single crewmember in the cockpit.
I believe Boeing have stated that unnecessary use of the quick donning masks reduces their life - one wonders if that could cause them to fail when really, really required?? :ooh:

In Japan use above 25,000ft remains - no doubt the rationale "...the B727 oxy mask was very difficult to use therefore..." or similar would be the justification, the fact it is a totally different mask to the 727 (the term "quick donning" a bit of a giveaway to the vast majority ;) ) will probably need pondering and consideration for at least the next 10 years (being generous!)

9/11 caused the demise of my 'retirement job' - when the bank pulled the plug on us. Generally I read of huge advances in technology and safety, but when I read that one crew-member is left on the flightdeck as the door is locked behind them, I'm left bewildered.

I realize there can't be a public answer to part of this issue, but just leaving one crew-member behind something that would even delay assistance has to be just plain wrong. There are several forms of incapacitation that leave the patient not just incapacitated, but literally flailing about. One outfit I worked for trained the cabin crew in containing such an occurrence.

LR, some of those huge advances in technology allow, erm, "alternative means" of getting back into the flight deck without being let back in, should it be necessary. I'm not telling you how though!

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.

Not true, mate. With the advent of the CCTV that requirement was removed. Not going to go into minute detail for the obvious security reasons, although I do appreciate how over-the-top that sounds :).

There's at least one major European airline that requires cabin crew to be on the flight deck when a pilot goes to the toilet. Coincidentally that same airline had an almost identical incident as the one mentioned here. Lost control at FL390 I think, after the autopilot gave up on the full deflection rudder trim whilst trying to open the door.
If it can happen - it will happen.

Fratemate

Thanks for that, wasn't aware the local regs allowed that option - was just speaking from general knowledge/undertnanding.
Questions: is it just an option under the regs or do some Japanese operators actually use CCTV as standard ops ?? Pax or freight or both??

Ta!

Our airline requires an F/A in the cockpit at night time if one of the pilots goes out of the cockpit but they put that requirement in the CC manual so no-one bothers. The other problem is that they have reduced the CC numbers and put cadets inthe RHS so I will reduce my caffiene intake and stay put.

Galdian,

Standard ops i.e. we use the CCTV all the time on the pax flights. It is, of course, on pax flights only, as there's no nasty people in the aircraft on the freighter (apart from the pilots) so there's no need for TVs (and the toilet is on the flight deck :))

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.

The rest of us have already been there and done that, and we are better prepared for these events. Including Pilots trying to retract flaps when gear up is called.:eek:

You are missing the important bit. Had the 64 year old captain had some
bladder control, this would never have happened.:p