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Boeing incidents/accidents due to Thrust/Pitch mode mishandling
Hi all,
Can anyone help me with Boeing (regardless of type) incidents that have been caused because the crew did not understand or use Thrust and Pitch modes correctly or if Thrust and Pitch mode was a related cause. From the top of my head: -Asiana 777 SFO -Turkish 737 AMS -FlyDubai 737 RVI -EK 777 Dubai Thanks |
The mishap report for Asiana at SFO is available. The Captain grossly mismanaged the autopilot modes, making several changes in rapid succession on final approach. Even after the 3rd pilot in the observer seat warned him twice, he did not correct. IMO, that was COMPLETELY pilot error.
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The easy way is to Google your request or Google each of the accidents you stated. There have been countless incidents/accidents of this sort. In almost every case the direct cause of the accident/ incident boiled down to the fact that the pilot was automation addicted and lacked basic instrument flying ability. Some may say that is a long bow to draw. Others may have the opinion that the pilot simply didn't know how to fly - a well established result of automation dependency..
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Originally Posted by Smooth Airperator
(Post 10269632)
Hi all,
Can anyone help me with Boeing (regardless of type) incidents that have been caused because the crew did not understand or use Thrust and Pitch modes correctly or if Thrust and Pitch mode was a related cause. From the top of my head: -Asiana 777 SFO -Turkish 737 AMS -FlyDubai 737 RVI -EK 777 Dubai Thanks You could also include China Airlines 006 in that, after an engine rollback, they failed to monitor their airspeed, resulting an a departure from controlled flight. Again, an underlying issue occurred, mode confusion was not the primary reason. |
Originally Posted by KRviator
(Post 10270060)
I wouldn't entirely classify the Amsterdam 737 accident as the crews fault. The primary cause was a faulty radar altimeter that provided an erroneous signal to the autothrottle that retarded the thrust levers. The crew manually advanced the thrust levers, but because he didn't disengage the autothrottle, the computer again retarded the thrust levers.
You could also include China Airlines 006 in that, after an engine rollback, they failed to monitor their airspeed, resulting an a departure from controlled flight. Again, an underlying issue occurred, mode confusion was not the primary reason. Pretty incredible you’d blame the AMS crash on anything other than pilot error If you’re so clueless you don’t recognize airspeed decreasing without an appropriate response from The autothrottles, then take over and correct you are incompetent, a passenger not a pilot Funny, we flew aircraft for decades without AT, how did we survive? |
Originally Posted by KRviator
(Post 10270060)
I wouldn't entirely classify the Amsterdam 737 accident as the crews fault. The primary cause was a faulty radar altimeter that provided an erroneous signal to the autothrottle that retarded the thrust levers. The crew manually advanced the thrust levers, but because he didn't disengage the autothrottle, the computer again retarded the thrust levers.
You could also include China Airlines 006 in that, after an engine rollback, they failed to monitor their airspeed, resulting an a departure from controlled flight. Again, an underlying issue occurred, mode confusion was not the primary reason. Same for the China airlines flight. They just sat there, never used rudder trim, let the speed drop until the autopilot gave up, and barely made it out alive. If we can’t handle stuff like this we don’t deserve to get paid to fly. |
Accident investigation has tended to move away from finding a 'root' or single cause as being responsible for an accident. Also, the practice of finding fault with the operator is also less prominent. People don't go out to deliberately make mistakes. In the 'pilot error' cases mentioned above, the modern accident investigator will look to why the pilots followed the actions they did. If they are as a result of not fully understanding the system, they will look at training/and or manuals. A good example of this, and another case for your study is the B737 serious incident at Bournemouth in 2007 https://www.gov.uk/aaib-reports/aar-...september-2007
The B737 accident at RVI has not yet had it's report published. Although the pitch/power couple with applying full power at a low speed is probably going to be considered a factor, I would strongly suspect that spatial disorientation will feature more. |
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Originally Posted by stilton
(Post 10270061)
Pretty incredible you’d blame the AMS crash on anything other than pilot error
If you’re so clueless you don’t recognize airspeed decreasing without an appropriate response from The autothrottles, then take over and correct you are incompetent, a passenger not a pilot Funny, we flew aircraft for decades without AT, how did we survive?
Originally Posted by hans brinker
(Post 10270064)
I disagree. The only reason we still have pilots is for when **** hits the fan, anything else can be automated. The radar altimeter failed and that led to the auto thrust to go to idle. The FO pushed the throttle up, let go, it went back to idle, and for the next 100 seconds all 3 of them sat there while the thrust was at idle, and the speed dropped to 83kts, 40kts below Vref.
Same for the China airlines flight. They just sat there, never used rudder trim, let the speed drop until the autopilot gave up, and barely made it out alive. If we can’t handle stuff like this we don’t deserve to get paid to fly. Yes, the crew screwed up (in both AMS and AF447...), in a massive way. I am not disputing that fact at all, nor trying to absolve them of that claim. But... Amsterdam was not, in itself, the fault of mode confusion, or automation dependency. The crew recognised the decaying speed, and that the throttles retarded automatically. They then pushed them up, and believed (and this is where their lack of systems understanding failed them) they would stay there - and through lack of basic airmanship, let the speed decay to a point where the accident was inevitable. Consider the case of Scandinavian 751. Engine surge on the initial climb, pilot does the right thing and reduces power. But the autothrottle restored power on the engine, resulting in dual engine failure and the ensuing crash. The pilot knew nothing about that 'feature', nor did the airline. Is it still their fault for not noticing the increasing power? The moral of the story is, pilots screwup certainly. But rarely does that, in itself, cause an accident and it is fatally simplistic to simply lay the blame for a prang at the feet of the crew. |
(and this is where their lack of systems understanding failed them Once upon a time we took responsibility for our own actions. In other words we stuffed up by over-controlling during on the flare, or left the power on for too long and floated off the end of the runway. Now we see the tendency to get out of trouble by blaming everything else except ourselves. The Amsterdam crash was a massive pilot cock-up from the time the autothrottles closed during final to the final impact. It was nothing to do with lack of systems knowledge. One theory came from a first officer of that airline and that was ethnic culture played a significant role in that accident. The cockpit gradient with the former military trained captain was so steep that neither of the two officers would have dared to take decisive action to prevent the accident lest they caused loss of face to the captain. The operative word being decisive. |
You old codgers can rant and rave all you like. The concept that a perfectly serviceable autothrottle system would just stay asleep when the speed was 30 knots below Vref is ludicrous.
Originally Posted by A37575
One theory came from a first officer of that airline and that was ethnic culture played a significant role in that accident. The cockpit gradient with the former military trained captain was so steep that neither of the two officers would have dared to take decisive action to prevent the accident lest they caused loss of face to the captain.
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Originally Posted by KRviator
(Post 10270126)
...Yes, the crew screwed up (in both AMS and AF447...), in a massive way. I am not disputing that fact at all, nor trying to absolve them of that claim.
But... Amsterdam was not, in itself, the fault of mode confusion, or automation dependency.. It was crew error, no more, no less. If it was not, then: - blame all the other crew for being able to fly the plane with the same problem in the weeks before (as analytical data has shown on the failed system involved it had flown many sectors with this failure present); - blame all the other crew for not reporting the defect through the tech log accurately enough so it could get fixed; - blame the engineers for not testing and repairing a reported system for failures, I'll help you: BITE check to see FAULT history... Flying with a hidden defect is one thing, covered by MEL/CDL etc... Flying with an unreported defect is another, blame the prior crews for not reporting it to the airline engineers in the only way legally possible... Flying with a reported defect which has not had a fix attempted due poor system knowledge of engineers hides a lack of training for those engineers... Flying with a reported defect repaired by engineers as serviceable shows there is a different reason or repair has not solved problem... Either way, basic airmanship AVIATE, NAVIGATE, COMMUNICATE applies. AVIATE - monitor what the aircraft is doing, especially close to ground, hands on the controls, this includes thrust levers! This simple and effective measure would have avoided this accident and loss of life... It is the first thing you learn when flying on your first day in the plane, the crew did not do it. The failed component was not noticed, was not disconnected, was not recognised: crew error! If you see throttles retarding and you are expecting thrust on engines, surely you would not only stand thrust levers up, you'd keep your hand on to ensure they stay there! |
Are you denying that culture has had nothing to do with any prangs? For example: Training a Chinese cadet during a 737 type rating he was asked by his simulator instructor what action he would take if on a highly unstable approach and it was clear the captain was pressing on regardless of all warnings from the co-pilot and there was every indication that the aircraft would likely over-run after touchdown. The cadet remained silent refusing to answer the question. The instructor gave him another chance and said would you consider taking over control from the captain and initiating a go-around? The cadet looked at the instructor horrified and said he would NEVER consider taking over control from a captain under the circumstances described. That, my friend, is culture and the bane of common sense flight safety. Blind obedience to authority will never change in some cultures. |
Both statements can be simultaneously true:
A) The system is poorly designed, which contributed to the accident. B) The pilots committed an error, which contributed to the accident. The system caused an undesirable aircraft state, and the pilots didn't catch it due to whatever combination of complacency, distraction, automation dependency, etc. It's not quantum chromodynamics. |
A problem with open-ended questions is that you can find whatever you look for. Viewpoint, analysis, opinion, are all biased by the inherent human condition. There would be greater safety benefit in considering the range of situations and context which humans have to manage. The assumption in this is that humans are influenced by the situation much more than we wish to admit or are able to identify, and thus we like to jump to easy conclusions - hindsight bias. In most circumstances it helps to consider the human as an asset opposed to a hazard; people are doing their best in situations as they are perceived - by them, at that time. I doubt that any of the accidents quoted involved lack of technical understanding alone; accidents involve many interacting factors, often without a dominating feature. It’s equally possible for a highly qualified crew with good technical understanding, but still encounter a situation where an appropriate understanding is not recalled or misapplied - just being human. Thus system design or situations might dominate, overcoming human ability in those circumstances. It is disappointing that several of these accidents involved weak technical features which had previously been identified, but for various reason deemed acceptable. 777 AT has known mode weakness, 737 Rad Alt was an old, but allowable design, but different variants of aircraft incorporate auto flight alerting or disconnect software, providing additional indications, this was not fitted to the particular aircraft. N.B. Combinations of Training flights, ATC influence, and technical weakness. Other accidents, more than those listed, involved situations where technology has been used to guard against adverse human activity (beyond reasonable human ability), but following technical failure of these guards there is the expectation that the human will manage the resulting situation - a situation beyond reasonable ability (§22) AF 447 involved conditions beyond those assumed in certification, technology was lacking thus it has been changed; not so (AFAIK) for the lack of comparator warning in the CRJ (Sweden). Similarly for TOCW MD80 in MAD, particularly where more recent aircraft types have an alert for TOCW failure / MEL operation. At some point during investigations and reporting of accidents, collective conclusions are formed e.g. ‘LoC’, yet timeline-wise LoC was consequential, involving human understanding and action after the initiating event - a change in situation. This view argues that there would not have been an accident without the technical malfunction, yet there other non technical examples involving wider operational and environmental aspects which also influence human behaviour, thus technical issues are not a complete answer. Additionally if the industry has accidents in rare circumstances which involve greater than the assumed probability of occurrence, then we have to question if the regulations or assumptions should be changed; who determines the cost benefit, who pays. Perhaps the industry’s very good safety record is approaching a point of ‘So Far As Is Reasonably Practical’; then what. |
A) The system is poorly designed, which contributed to the accident. B) The pilots committed an error, which contributed to the accident. |
Originally Posted by hans brinker
(Post 10270064)
I disagree. The only reason we still have pilots is for when **** hits the fan, anything else can be automated. The radar altimeter failed and that led to the auto thrust to go to idle. The FO pushed the throttle up, let go, it went back to idle, and for the next 100 seconds all 3 of them sat there while the thrust was at idle, and the speed dropped to 83kts, 40kts below Vref. Same for the China airlines flight. They just sat there, never used rudder trim, let the speed drop until the autopilot gave up, and barely made it out alive. If we can’t handle stuff like this we don’t deserve to get paid to fly. |
Sorry to be simplistic but when all the bells and whistles fail, if you are a pilot and I used to be one before I was forced to become an aircraft operator! You only need the old formula pitch and power equals performance. every aircraft works like a Cessna, piper etc. I despair at the state the industry is in when it comes to piloting skills and I only see a small snapshot. |
Originally Posted by underfire
(Post 10270691)
So if the pilot does not understand the if/thens and the cascade of sequences involved in the system processes, it is the systems fault?
It's a mistake to take a moralistic stance that looks to assign fault. The pilot screwed up then what, now we can harumph sanctimoniously and feel better about ourselves? No, in the end, people's skulls get splattered and any factor that increases the likelihood is an area to focus on for improvement. It doesn't mater whose "fault" it is. |
There was a time when us 'old codgers' as Capt. Bloggs calls us, had to do upwards of 1500 to 4000 hours before we got anywhere near flying a shiny jet and most of that time would be spent single crew flying light twins, in all weathers, with levels of automation that ranged between nothing and not very much, our natural reaction, when things started to go wrong was to dump the automatics and fly manually, (not always a good idea). We had to be taught to believe in the automatics and bide our time and try and solve problems though the automatics, if the automatics didn't solve the problem itself. Todays 'Child of the Magenta Line' has no basic flying experience of any depth to fall back on so when things go wrong and the pilots don't fully understand the capabilities and limitations of automatics and are convinced the automated systems are more competent than the pilot and will always save them, then disaster is only a short step away.
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A big problem is that "the automated systems are more competent than the pilot" is largely a true statement. From what I've seen in general, I would place more stock in the automation saving the pilot, than the other way around.
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Originally Posted by Vessbot
From what I've seen in general, I would place more stock in the automation saving the pilot, than the other way around.
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I am reminded of Murphys original quote, (not the often misquoted "Murphys Law")
One day, after finding that a transducer was wired wrong, he cursed the technician responsible and said, "If there is any way to do it wrong, he'll find it." |
Originally Posted by parabellum
(Post 10270759)
Todays 'Child of the Magenta Line' has no basic flying experience of any depth to fall back on so when things go wrong and the pilots don't fully understand the capabilities and limitations of automatics and are convinced the automated systems are more competent than the pilot and will always save them, then disaster is only a short step away.
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I'm always amazed by the extent that pilots are willing to blame our colleagues for assumed screw ups while secretly hoping we don't make the same mistake. And when it comes to accident investigation, blaming the operator is the easy way to get to a conclusion. In the Asiana accident at SFO, I've heard many times that it was pilot error - even mainstream media in the US made a joke about it.
But modern accident investigation has moved on from simply blaming the operator as it doesn't stop the same or a similar incident from recurring - which is the primary aim of holding the investigation in the first place. In this incident, you have to look at why the crew didn't manually apply thrust on the approach. By saying "they were stupid" stops the investigation right there and then. You think you have found the issue and when the airline trains their pilots better, the problem goes away. That's until it happens again - which it probably will. But a thorough multi level investigation will look at the Airline's SOPs, their training system, their culture etc. And as the system correctly maintained and working as it should? Were the crew fatigued? Did they get their mandated rest period? Does the airline have fatigue mitigations in place? It will look at the airline's regulator to see how effective it is in ensuring training and safety standards are met. Then it will look at the design of the AT system. Is it fully understood by other operators using substitution tests, have there been similar incidents reported? Are similar incident actually being reported perhaps distorting the true picture? What was the certification process that led to the system being included - was it effective and did it consider all the threats at pitfalls? So much to consider! I've flown a similar type with the Thrust Hold AT mode which caught the Asiana crew out. I was warned about it during training and that it can seriously bite you on the bum. Despite the warning in training, I've witnessed the speed reducing while a pilot says "What's it doing now?" to be told "Thrust Hold mate!" on many an occasion. I've done it myself! And at the end of a 14 hours sector after some dodgy crew rest, making an approach in tricky conditions at an unfamiliar airport in a new aircraft in your window of circadian low, I can see how all the factors stack up to make an accident like this more likely. Sure, the crew made an error. But just by pointing the finger at the user will not address all the factors. And if you ask me my opinion about this accident, I would have to ask why the manufacturer thought it was sensible to have an AT mode which tells you the AT is working, but doesn't let you know the thrust levers won't move. |
Well said, Dan.
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And if you ask me my opinion about this accident, I would have to ask why the manufacturer thought it was sensible to have an AT mode which tells you the AT is working, but doesn't let you know the thrust levers won't move. The children of the magenta line line trope is getting tired. I’m more concerned about someone who is reluctant to embrace change (look at the incomprehensible Boeing FMAs) and who thinks that everything in aviation is lightning fast reactions and seat of the pants skills. |
Originally Posted by Capn Bloggs
(Post 10270198)
You old codgers can rant and rave all you like. The concept that a perfectly serviceable autothrottle system would just stay asleep when the speed was 30 knots below Vref is ludicrous.
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Originally Posted by KenV
(Post 10271347)
Is it? Really? The autothrottle system was dependent on the rad alt, so when the radalt failed, the autothrottle failed. The flight crew is not dependent on the radalt. Changing the above statement slightly results in the following truism: The concept that a flight crew would just stay asleep when the speed was 30 knots below Vref is ludicrous.
In my opinion, the last three decades of design and operational use of automated systems in the flight deck has gradually led to less vigilant instrument pilots. Everything works so well, almost all of the time, and when it doesn't it may not be obvious, except to a vigilant grew watching the instruments instead of the system. I don't blame the pilots, they are the victims of this systematic paradigm shift. Considering how important airspeed control is during the final approach, who would have guessed that pilots would be so inattentive (for two minutes, and this isn't the only such accident)? Unless you have been in the situation after hundreds (thousands) of approaches when "other things" held their attention, and nothing went wrong. Think how much "better" things will become when airlines achieve their goal of single pilot airline crews, and/or "warm body" co-pilots. |
Fly the plane, that’s what you are there for. The automation is an aid. Those of you that can’t grasp the concept that the pilot is solely responsible for the flight path, and not the autopilot, need to grow up and finally take responsibility for what you are doing. Stop blaming the system for incompetence. Its a scary aviation world we are getting in to, where the new generation of pilots are looking to blame the system for unintended and undesirable flight paths, rather than take responsibility for being the Pilot in Command! The Boeing automation is simple and easy to understand. All you have to do is read the books.... Boeing also assume competent and trained pilots are flying their aircraft. What an outrageous assumption to make!!! Who would think that competent and trained pilots would be in command of jet transport airplanes! Oh the horror of requiring such a thing!! :rolleyes: grow up. |
If a technical systems fails / malfunctions in circumstances leading to a hazardous situation, and where comparable systems / aircraft provide sufficient mitigation against this hazard, then irrespective of human performance, assumed or otherwise, then the deficient technical system should be corrected. The debate in the above is with what is assumed to be hazardous. The technical outcome of an accident is objective fact; but the assessment of human performance either with hindsight or expectation in future situations is always subjective, uncertain. ‘Precautionary Principle’ … defines actions on issues considered to be uncertain, for instance applied in assessing risk … "… caution practised in the context of uncertainty" … |
I would also suggest that during the design and certification of the system, the safety analysis assumed a trained and competent aircrew, too. With hardly any change in such assumptions from the 60's and 70's. My understanding is they finally upgraded the DAL of the autothrottle to 'A' on the 787 (although I don't know that for a fact). And at the end of a 14 hours sector after some dodgy crew rest, making an approach in tricky conditions at an unfamiliar airport in a new aircraft in your window of circadian low, I can see how all the factors stack up to make an accident like this more likely. |
Originally Posted by Capn Bloggs
(Post 10270812)
The problem Vessbot is that you haven't seen (do you fly?) all the saves that have been made by pilots but which don't get reported. AF 447 alone, I think I read that that event (or similar) had occurred 30 times previously, but with no dramas as the situation was recovered by the pilots. Bad design, pilot save. When finally pilots don't save it, much gnashing of teeth occurs blaming the drivers, who are themselves victims of Magenta Line policies of the regulators, operators and manufacturers.
When we're getting vectored to expect a tight visual because of a storm on long final, and he's nervously fidgeting with the heading knob a few degrees back and forth while telling me not to call it in sight yet, instead of just flying it in, it's clearly revealed to me which way the automation/pilot/saving relationship is arranged. |
tdracer, that's probably not worded to describe precisely the SFO accident. Anyhow the energy level was tricky. Intercepting a standard 3 deg profile from above, with a rather low-and-close geometrical intersection point is a beast. Your mind is firmly set that you are hot and high, so you WANT idle thrust....
and then ... In fact, as you intercept the G/S, heaven forbid the AP or pilot pulling up to capture it - oh wait, there is no other way - the A/C if still with idle thrust is in a SEVERE low energy state. Add to that a bit more pull to recover the duck-under (no matter A/P or human) and you have a 7n7 with a 6-8 degree DOWN trajectory vector, full landing flap with L/G down and 5 deg NU pitch to recover the profile and it is an extremely high drag configuration. The inertia is massive. If not anticipated it all happens very fast and the recovery N1 is in the low 80s. Feel free to ask how I know. Another trap is how un-common it is. These days especially long-haul it is ILS to ILS and stable-coupled from 15 NM. And guys get about 2 landings a month each. The chances of recognizing not only that the situation is wrong, but how quickly and deeply bad it is about to become are practically nil. And then you are left with the reactions. Why theirs came late is elementary HF. In this respect both AMS 737 and SFO 777 wouldn't have happened if it was not for the intercept from above to begin with, I am quite convinced. |
Originally Posted by Ken V
Is it? Really? The autothrottle system was dependent on the rad alt, so when the radalt failed, the autothrottle failed. The flight crew is not dependent on the radalt. Changing the above statement slightly results in the following truism: The concept that a flight crew would just stay asleep when the speed was 30 knots below Vref is ludicrous.
Originally Posted by Switchbait
Fly the plane, that’s what you are there for.
The automation is an aid. Those of you that can’t grasp the concept that the pilot is solely responsible for the flight path, and not the autopilot, need to grow up and finally take responsibility for what you are doing. Stop blaming the system for incompetence. Its a scary aviation world we are getting in to, where the new generation of pilots are looking to blame the system for unintended and undesirable flight paths, rather than take responsibility for being the Pilot in Command! The Boeing automation is simple and easy to understand. All you have to do is read the books.... Boeing also assume competent and trained pilots are flying their aircraft. What an outrageous assumption to make!!! Who would think that competent and trained pilots would be in command of jet transport airplanes! Oh the horror of requiring such a thing!! :rolleyes: grow up. |
Switchbait. Fly the plane, that’s what you are there for. The automation is an aid. Those of you that can’t grasp the concept that the pilot is solely responsible for the flight path, and not the autopilot, need to grow up and finally take responsibility for what you are doing. Stop blaming the system for incompetence. Its a scary aviation world we are getting in to, where the new generation of pilots are looking to blame the system for unintended and undesirable flight paths, rather than take responsibility for being the Pilot in Command! The Boeing automation is simple and easy to understand. All you have to do is read the books.... Boeing also assume competent and trained pilots are flying their aircraft. What an outrageous assumption to make!!! Who would think that competent and trained pilots would be in command of jet transport airplanes! Oh the horror of requiring such a thing!! :rolleyes: grow up. Bloggs A well-rounded, balanced view of the current state of the industry... There is absolutely nothing in placing blame where blame belongs. The system is there to HELP you fly the ac. The pilots job is not to be there to take over when the automation makes a mistake. ummm, never mind, that was not the original intention of the automation. |
Originally Posted by Underfire
Well stated.
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If what Tdracer has added is true, it seems Boeing has had a change of heart with the 787. To the the poster who says that the Boeing FMAs are easy to understand if you read the manuals: I put to you VNAV climb or descent, where there is no indication whatsoever on the FMAs (or PFD for that matter) that the aircraft will or will not level off at some intermediate altitude. It can’t even handle the job of making a constraint that’s referenced to STD while QNH is set, or vice-versa. Or the fact that approach mode only works for IAN and not an RNAV approach with multiple constraints; or the fact that you can’t arm APP until established on the localiser / FAC; or that you have to do a silly pressurisation sequence of the hydraulics / fuel pumps before engine start even though they’re all load shed anyway; or that it has no comprehension of passenger comfort in VNAV descent; or that it will exceed its thrust capability in HDG SEL at high altitudes; or that you have to use a mouse pointer to click on dinky virtual FMC buttons; or that doing direct to a waypoint doesn’t automatically engage a navigation mode; or the hold entries that would fail an IR; or the most annoying trait of all of making you tweak the HDG bug every minute or two for FOURTEEN HOURS STRAIGHT because they couldn’t figure out how to slave it to the actual heading. Feel slightly better for getting that off my chest. |
A now retired simulator instructor at Boeing told me they designed the 787 on the assumption it would be flown by incompetent pilots; hence all the protections.
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Originally Posted by Centaurus
(Post 10272012)
A now retired simulator instructor at Boeing told me they designed the 787 on the assumption it would be flown by incompetent pilots; hence all the protections.
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