Crews incorrectly select

[Guest]

Flybe monitors director modes after Q400 dive incident

• 08 November, 2018
• SOURCE: Flight Dashboard
• BY: David Kaminski-Morrow
• London

UK regional operator Flybe has introduced flight-data monitoring to check for pilots’ incorrectly select flight-director modes before take-off, following a serious incident involving a Bombardier Q400 departing Belfast City.

As the aircraft climbed to 1,350ft the crew engaged the autopilot, but the turboprop responded by pitching down and rapidly descending.

 

The aircraft’s systems issued sink warnings and a “pull up” order to the crew, and the captain recovered the descent at 928ft after disconnecting the autopilot, says the UK Air Accidents Investigation Branch.

Analysis showed the aircraft lost 500ft in around 18s and reached descent rates of 4,300ft/min.

It found that the aircraft’s flight-director modes had not been set correctly before the Q400’s departure – pointing out that the crew was under time pressure – and the inquiry turned up three other incidents, all occurring last year, involving similar incorrect settings on Flybe Q400s.

Two of these other three events also involved pilots’ rushing to expedite departure or mitigate delays, the investigation states.

Revision of a loadsheet had threatened a delay and the captain, the flying pilot, had chosen to complete several tasks before pushback, including setting the flight-director modes.

He selected the ‘go-around’, ‘heading’ and ‘altitude select’ modes but did not enter a target departure clearance altitude.

The inquiry states that, unbeknown to the crew, the flight-director sequence entered by the captain resulted in mode changes, including a default switch to ‘altitude’ mode, which were not detected by the pilots.

Flybe’s training regime mentions the importance of setting the target altitude before the flight-director modes, warning that the system could otherwise capture the aircraft’s current altitude – which would be ground level.

Although the captain, during line-up, noticed that ‘altitude select’ was not displayed, choosing this mode when ‘altitude’ is also selected does not change the target altitude.

The target altitude should have been 3,000ft but the system had already captured a ground-level setting.

As the aircraft’s autopilot was engaged during the climb, it attempted to reach this incorrect target altitude, putting the turboprop into a dive.

“The [captain] reacted promptly in accordance with the trained sequence of actions and returned the aircraft to a safe flightpath,” says the inquiry.

Flybe has introduced a check to its flight-data monitoring scheme which will look for instances of incorrect flight-director mode selection before departure, it adds.

None of the 48 occupants of the Q400 (G-ECOE) was injured during the incident, which took place on 11 January this year.

[Guest]

• Azur 757 nearly stalled after mode switch during climb

Azur 757 nearly stalled after mode switch during climb

• 24 July, 2018
• SOURCE: Flight Dashboard
• BY: David Kaminski-Morrow
• London

Russian investigators believe an inadvertent mode change led an Azur Air Boeing 757-200 to pitch up, lose airspeed and nearly stall shortly after taking off from Goa.

The aircraft (VP-BLV) had been transporting 232 passengers and seven crew members on a charter service to Rostov-on-Don.

Federal air transport regulator Rosaviatsia says it departed with a take-off weight of 113.5t, close to the maximum of 115.9t, and had been climbing with a 5° flap setting. The 757 was operating under visual meteorological conditions.

As it neared 2,750ft the aircraft’s airspeed bled away to 134kt, below that required for the configuration, after it experienced an “uncontrolled” increase in pitch to 29.4°, says Rosaviatsia.

The crew was alerted by visual and aural warnings, as well as the stick-shaker, and the captain immediately acted to counter the approach to stall, disengaging the autopilot and pushing the control column forward, pitching the aircraft 2.2° nose-down.

It entered a descent with a vertical speed of more than 3,800ft/min. The stick-shaker stopped and the aircraft’s thrust was increased to near-maximum in order to recover.

Analysis of the flight-data recorder, says Rosaviatsia, shows that the aircraft had reached a height of 885ft and a speed of 200kt when – simultaneously with a switch to a lower engine thrust setting – the ‘vertical speed’ mode engaged.

“This mode was probably erroneously activated by the first officer,” says Rosaviatsia, pointing out that standard operating procedures do not involve using vertical-speed mode at this point in flight.

Some 1.5s after this mode activation the ‘flight level change’ mode was engaged for 3s and the autopilot’s channel ‘C’ was automatically switched on. As this channel activated, the autopilot – for undetermined reasons – entered vertical-speed mode with a climb rate of nearly 3,700ft/min.

By this point the jet’s airspeed had started declining from 201kt to 195kt. The aircraft attempted the high climb rate without a change in engine power, and its airspeed continued to fall.

Calculations show that the aircraft would only have been able to climb at 1,600ft/min without losing airspeed.

Rosaviatsia says it does not have a record of the cockpit conversation, which means it is unable to give an “unequivocal” analysis of the pilots’ interactions.

But it says there is sufficient evidence to suggest the crew probably failed to monitor and mention the changes of autopilot modes. The entry into ‘vertical speed’ mode instead of ‘flight level change’, it states, led to an increase in angle-of-attack and a loss of airspeed.

Rosaviatsia says insufficient crew-resource management contributed to the situation, and is pressing for improved simulator training and increased awareness among pilots of the 757 incident, which occurred on 6 February last year, and techniques for in-flight upset prevention and recovery.

Investigators are probing another incident involving an Azur 757-200, on 16 June this year, during which the aircraft experienced excessive pitch and bank while attempting to land at Antalya.

[Wolfhunter]

With an IMHO caveat entered in the preselector and ALT SEL engaged, I can’t help but believe technology and automation have conspired to desensitize  pilots from what the aircraft is doing and it’s leading to unreasonable delays in reaction to deviations at low altitudes. Picking the appropriate level of automation for the task at hand strikes me as a lost art and cross check speed, air picture and basic flying abilities have tubed as a result. Very noticeable with the foreign pilots I've seen doing recurrent sims in Canada....

How many folks fly raw data departures when it’s reasonable to do so? I used to make a point of it… maybe that’s why I’m driving a dump truck now eh? It seems to me that (for the most part) a  hand flown, raw data ILS to minimums is an aircraft control emergency now; I remember when it was an everyday occurrence.

In any case, I have posted this before but here it is again incase some have never seen it. A bit dated perhaps but the wisdom here is timeless IMO. Cheers.

 

 

 

[blues deville]

....“after it experienced an “uncontrolled” increase in pitch to 29.4°”.......The crew was alerted by visual and aural warnings, as well as the stick-shaker, and the captain immediately acted to counter the approach to stall, disengaging the autopilot and pushing the control column forward, pitching the aircraft 2.2° nose-down.

 

Immediately could be a stretch. 

[J.O.]

If you need visual and aural warnings and a stick-shaker to tell you the pitch is at 29.4°, you need to rethink your chosen vocation.

[vanishing point]

Have pilots truly forgotten how to fly airplanes?  Airplanes all fly on the same principles.  I’m all for automation and technology but not at the expense of the theory of flight.

[DEFCON]

It seems so simple; if the automation isn't pointing the aircraft where you want it, no matter the type, you're only one 'click' away from having a raw data airplane to fly?

It's amazing to see that aircraft are being lost fairly frequently anymore following an automation failure while operating in benign weather conditions only because the pilots were reluctant, or even incapable of manually flying the plane for one reason, or another.

I wonder if safety would actually be enhanced if pilots were 'encouraged' to build & maintain hands on flying skills during normal ops, or would the practice result in an increase in the number of incidents etc.?

 

 

[boestar]

On 11/8/2018 at 7:36 PM, vanishing point said:

Have pilots truly forgotten how to fly airplanes?  Airplanes all fly on the same principles.  I’m all for automation and technology but not at the expense of the theory of flight.

Automation can make your 757 hover.  didn't you know that? 

[Guest]

El Al 787 struggled to lift off after 40t weight-data error

• 27 November, 2018
• SOURCE: Flight Dashboard
• BY: David Kaminski-Morrow
• London

Israeli investigators have determined that a 40t weight error in take-off performance calculations caused an El Al Boeing 787-9 to struggle to become airborne from Tel Aviv.

Analysis of the preparations for the 29 March flight to Newark found that the captain had entered a zero-fuel weight of 128t, some 40t lower than the actual figure of 168t.

The twinjet rotated at 154kt, less than its minimum-unstick speed, when it would otherwise have been travelling at around 175kt.

Israel’s air accident investigation authority states that the rotation speed was roughly that of the 787’s stall speed.

As a result, it says, the aircraft responded “lazily” to the rotation command and failed to lift off until its speed increased. The geometry of the situation caused a tail-strike protection system to activate.

“The delay in lifting the nose contributed to the aircraft’s gaining speed before it began to climb and thereby avoiding stalling or loss of control,” says the inquiry.

The aircraft, assisted by ground effect, reached only 35ft some 13s after rotation was initiated.

While the climb was executed at reduced thrust, the speed was sufficient to avoid any significant impact on the manoeuvring margins.

Flap retraction also took place at speeds lower than those required by the aircraft’s actual weight, but there was “no hazardous increase” in the angle of attack, says the inquiry.

Once the aircraft had reached 20,000ft the pilots realised the error, because the flight-management system recommended an optimum cruise altitude of 38,000ft rather than the typical 34,000ft.

This was not only unexpected, for an aircraft transporting 282 passengers and 18 crew members on a transatlantic service, but was also higher than the altitude it could have achieved in the early phase of flight.

“It was impossible to climb to this altitude,” says the inquiry. The crew immediately understood that the take-off performance had been incorrectly calculated, informed the airline’s control centre, and rectified the error in the flight-management computer.

Investigators state that the aircraft had arrived at Tel Aviv late, and this put time pressure on the crew during preparation for the Newark service. Weight and balance documents were transferred to the crew for review immediately upon their arrival at the aircraft.

While the captain entered an incorrect zero-fuel weight during take-off calculations, he noticed the error. But the inquiry says he “probably” entered the wrong data again while trying to correct it.

Investigators say the first officer did not conduct effective cross-checking of the data, as required by operating procedures, and opportunities to identify the error were missed.

El Al has been undertaking a fleet modernisation with 787s. The aircraft involved (4X-EDB) had only been delivered to the carrier five months earlier.

The inquiry suggests the lack of experience on the type contributed to their failure to notice the deviation from performance figures which would have been more reasonable.

Acceleration during the take-off run was substantially lower than normal, but the departure took place in darkness and the inquiry states that abnormal acceleration is difficult to discern under such conditions

[blues deville]

Will have to include keyboard typing classes for all future pilot training. 60 words (and numbers) per minute.

[Bobcaygeon]

It's not automation its simple garbage in = garbage out.

I never been able to hand fly a great ILS to minimums when I had the VOR freq. dialed in.

Are some of these issues new? No. It''s concerning that some of them still happen even with the automation/ tools available to them.

How many accidents have happened because of bad math, running the wrong perf chart, etc.

Big picture there's also a crap load more aircraft traffic than there was when automation much more basic.

If we had the 1980 accident rate we'd be reading a lot more accidents. 

Media wise, in 1980 these things could have happened 2 provinces away and we might not ever even know about them.

 

  

 

 

 

 

 

 

 

[Bobcaygeon]

Just now, blues deville said:

Will have to include keyboard typing classes for all future pilot training. 60 words (and numbers) per minute.

Or make you type it in twice like when you change your password

[conehead]

Why are pilots still inputting this data manually? There must be a better (safer) way..

[blues deville]

1 hour ago, Bobcaygeon said:

Or make you type it in twice like when you change your password

Not a bad idea actually. Especially for take off performance. 

[DEFCON]

This looks a lot like the SunWing 737 report from last week.

Shouldn't someone be asking why the 787 crew took the aircraft to 20K in the first place?

A lack of familiarity with type is one thing, but this aircraft was giving the crew all kinds of big hints that something was 'seriously' amiss, even the media can see that, and yet they continued on course instead of retreating to a safe position back on the ground?

Ask yourself:

- if you were sitting in a rotated attitude for 10 plus very long seconds and not going anywhere, wouldn't you know that something was wrong ... even if this was your first flight on type?

- if it took 13 seconds to get to 35', it must been a very long trip to 20K. Wouldn't you think a number of mental flags should have been popping up throughout the climb?

- why aren't pilots watching the engine numbers during t/o and if they are, why are they failing to recognize all the indicators of 'abnormally' low power and then manually setting thrust to something close to normal for the WAT without exceeding engine limitations?

- is the modern pilot conditioned to respond to colours and chimes and leave the details to automation after they've entered the data?

- is anyone monitoring engine and aircraft performance the way it was done in the days before automation became king?

... and so many more questions.

 

[blues deville]

1 hour ago, conehead said:

Why are pilots still inputting this data manually? There must be a better (safer) way..

A lot of data can be transmitted/received (flight plans, upper winds,etc) if you want to pay for the service. For me, take off performance no matter how it was calculated has always been a manually input function by either pilot depending on the procedures.

[J.O.]

I recall AC was working on a ACARS upload of takeoff performance data. Has that been implemented?

[st27]

JO......the AC operation still has load final transmitted and pilots request WAT data based on weight/temp/runway in use etc.

[DEFCON]

Thanks Rich

 

"How is retreating safer? They didn’t know their weight, so how could they calculate safe approach speeds? They couldn’t even safely decide how much fuel to dump in order to get down to landing weight. If they had taken the time to sort out those numbers, then they’d know their actual weight and be safe to continue."

The crew clearly didn't know what was going on with their aircraft. Taking the aircraft further down range and away from safety when you are experiencing a serious situation you can't immediately and fully appreciate has proven to be a bad plan on a number of occasions; the Swiss Air MD 11 crash at Peggy's Cove comes to mind.

 

"- if you were sitting in a rotated attitude for 10 plus very long seconds and not going anywhere, wouldn't you know that something was wrong ... even if this was your first flight on type?"

"Probably. Response... select TOGA thrust and carry on."

Exactly, but just like the SW crew, this one just sat on their hands throughout the takeoff roll and let fate have its way?

Don't you wonder why?   

 

"I don’t know any pilot who knows what’s “close to normal” numbers for any given combination of aircraft weight, pressure altitude, runway length, runway gradient, temperature, obstacle clearance, wind, etc."

That's interesting because I do.

Besides, the report from the inquiry seems to tells us 'familiarity with WAT etc was at issue ... 

"Once the aircraft had reached 20,000ft the pilots realised the error, because the flight-management system recommended an optimum cruise altitude of 38,000ft rather than the typical 34,000ft.

This was not only unexpected, for an aircraft transporting 282 passengers and 18 crew members on a transatlantic service, but was also higher than the altitude it could have achieved in the early phase of flight.

“It was impossible to climb to this altitude,” says the inquiry. The crew immediately understood that the take-off performance had been incorrectly calculated, informed the airline’s control centre, and rectified the error in the flight-management computer."

 

 

 

 

 

[blues deville]

8 hours ago, st27 said:

JO......the AC operation still has load final transmitted and pilots request WAT data based on weight/temp/runway in use etc.

777 is EFB and 767 WAT data via ACARS. All take off solutions or data are completed manually by pilot input. 

[Homerun]

9 hours ago, Rich Pulman said:

Wow! That seems like an awfully high unstick speed. Is a 175kt Vr normal for a B787?

For comparison, a Vr of 154kts could be used at maximum weight (242T) on an A330.

For weights close to max, yes the Vr is in the vicinity of 175 on the 787.

The 787 very much relies on its wing and velocity to get itself airborne as opposed to brute force from engine thrust.  This is amplified by procedures that see a tremendous amount of thrust reduction used when able.  Not only do you use an assumed temperature, but you can also use up to 2 fixed derates, 10% and 20% plus the assumed temp reduction.  If you have a very long runway and no obstacles, then you will see a lot of thrust reduction and very high V speeds.  With all of the variables that go into the performance calcs, its very difficult to come up with a rule of thumb number for a takeoff N1 setting.

If you want to increase to max thrust during the t/o roll or rotation, its not quite as simple as the Airbus where you just shove the thrust levers into TOGA.  On the 787, the fixed derate you are using is considered a limitation due to Vmc considerations as your speeds are based on that derate.  We calculate the max N1 for the given derate during preflight, and that is what we would use in the case where more thrust is needed.  This will be less than firewall unless you are using TO power (no derate). 

 

[Fido]

I seem to remember that when the A320 first came into service that it was seen that there was too much automation.

Now it appears that Boeing has claimed that trophy.

[Kip Powick]

When WD got the A310s, that aircraft was the worlds most technologically advanced  aircraft in the industry....It was a steep learning curve for everyone but as time passed and most everyone felt more comfortable with the "glass" small inklings of complacency would creep in, not life threatening, but errors of procedure. 

I remember one flight, tight for take-off time,  where the Capt said he would input the data and I could do the external walk around. I balked and said I would prefer if we both did it, one typing and the other reading and then double check by reversing roles. He agreed and as far as I know, that was they way we did it in every flight I was on. 

I felt it was doubly important if we were oceanic  and the T/O numbers, in my mind were the most  important.

40 minutes ago, Fido said:

Now it appears that Boeing has claimed that trophy.

As much as I prefer "stick and rudder" I feel it wasn't that there was too much  automation, (Lion Air),  but rather the fact that  the training on this model of 737 lacked  sufficient information about the A/AI and the ramifications if it went out of serviceable parameters.

Perhaps an attitude of complacency crept in with many pilots, especially if they had flown older 737s because on older models if there was an issue with trim issues, one could just over ride it manually and press on. Based on what I have read both here and on other forums, many MAX pilots were not fully aware of how the trim system worked, however, it is truly unfortunate that it had to take an accident of this magnitude to bring possible problems with the system and/or the training to the forefront.

[blues deville]

The A310 was certainly a nice aircraft and developed out of the A300 but the 767 was actually a year or two ahead of the A310.  Boeing also produced and sold a lot more of their widebody. The A310 had a reputation of being a hangar queen for some operators which probably didn’t help its sales. 

[J.O.]

9 hours ago, Homerun said:

If you want to increase to max thrust during the t/o roll or rotation, its not quite as simple as the Airbus where you just shove the thrust levers into TOGA.  On the 787, the fixed derate you are using is considered a limitation due to Vmc considerations as your speeds are based on that derate.  We calculate the max N1 for the given derate during preflight, and that is what we would use in the case where more thrust is needed.  This will be less than firewall unless you are using TO power (no derate). 

 

Admittedly it's a decade ago but when I flew an RR powered A330-300, the de-rate was also "locked".