DEFCON Posted August 29, 2003 Share Posted August 29, 2003 The TSB just released its report into the investigation of an incident involving AC 875 on June 14 2002. All that can be said is...WOW! Is it fair to ask if these two are still employed as ACP's and or pilots? Link to comment Share on other sites More sharing options...
B75/76 Posted August 29, 2003 Share Posted August 29, 2003 Any chance there is a link to the report? Is your suggestion that they shouldn't be ACPs and/or pilots at AC? Link to comment Share on other sites More sharing options...
Guest Nobias Posted August 29, 2003 Share Posted August 29, 2003 Here is the link for the report. I just read it and though it is one of those situations where their errors were consecutive and should have been caught, I certainly don't think that it's as shocking as DEFCON implied. Mistakes happen, it doesn't matter who you are... http://www.tsb.gc.ca/en/reports/air/2002/A02F0069/A02F0069.asp Link to comment Share on other sites More sharing options...
DEFCON Posted August 29, 2003 Author Share Posted August 29, 2003 yes mistakes can happen however, how does one end up at 27 degrees nose up VFR for 15 secs at 145 kts in a 330 and not recognize it as a problem? I'm not familiar with the Airbus technology but, the posted speed error catches ones attention like a punch in the nose not withstanding the coloured visual cues. Link to comment Share on other sites More sharing options...
UpperDeck Posted August 29, 2003 Share Posted August 29, 2003 Two wholly unrelated instances of a lack of situational awareness by two senior pilots in one flight either of which could easily have had catastrophic consequences. That seems to invite a little more censure than "mistakes happen". The media is trashed for faulting AC at every turn and with little "meat on the bone" to chew. Fortunate then that this incident managed somehow to avoid the glare of the media spotlight. Link to comment Share on other sites More sharing options...
Guest Saltaire Posted August 29, 2003 Share Posted August 29, 2003 I've flown the 330 and I can't believe what I was reading. Mistakes do happen and we've all been in situations that could have been handled differently, but I'm sorry, that is a very disturbing report. Link to comment Share on other sites More sharing options...
Guest Stone Posted August 29, 2003 Share Posted August 29, 2003 No, they are not currently employed by Air Canada. They conveniently took early retirement shortly after this incident, possibly with a little nudging by the Company. Link to comment Share on other sites More sharing options...
Guest Stone Posted August 29, 2003 Share Posted August 29, 2003 I might add that both gentlemen led exemplary careers with Air Canada, however this was a major screw-up that could have led to catastrophic consequences. It could not be overlooked. Air Canada did what any good company would do. They quietly and politely showed them the door. Link to comment Share on other sites More sharing options...
DEFCON Posted August 29, 2003 Author Share Posted August 29, 2003 Thanks Stone. One related issue leaves me wondering; the individuals involved appear to have been heads down during the early approach phase and the ac got away from them. In the modern day technology is pushed to the death which leads pilots to become very busy master typers which in turn leads to distractions from the basic "fly the airplane" principal. I'd bet these two are not alone in this regard. They're only the unfortunate ones that had something unusual happen while doing that which most of us are frequently guilty of. Link to comment Share on other sites More sharing options...
Guest V1 Posted August 30, 2003 Share Posted August 30, 2003 This class of error is known as a substitution error, where a character that was to be entered is substituted with erroneous information. Substitution errors result when information is initially misread, when information is mis-encoded at the time it is entered, or as a result of a human key entry error. It was not possible to determine the exact etiology of the substitution error in this occurrence; however, it is possible that the number "2", which is located directly above the number "5" on the keypad of the MCDU, was accidentally hit. Don't be to smug my friends, it is those who think they are immune that are actually at great risk. They even have a name for this type of error, any one of us could do just the same. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 Thats what I was thinking, but I didn't think it was my place to say it. But yep, my first thought to the originator of the thread... are you absolutely sure you could never have done exactly the same thing? Glass houses and all... Since some of you guys probably know these folks I think Stone should have simply said they retired. An unfortunate calamity of errors that they kept from becoming a disaster... They handled it. No need to toss mud their way. imo. Link to comment Share on other sites More sharing options...
Guest shibui Posted August 30, 2003 Share Posted August 30, 2003 Don't think anyone could agree with a shred of professional pride could agree with you there. While I am as substitutional error prone as the next monkey, I am certain that I could not possibly: -blithely accept a 123 knot V1 speed on airplane weighing 220 tons without at least a quadruple check of my calculations -rotate 20 knots under Vr, much less at over 3 degrees per second -get 30 degrees nose up within a few thousand feet of the ground without at least a small exclamation of general dismay. Anyone who could say "there but for the grace of God go I" about those little gems had better retire immediately. For all the good these guys were doing their trusting passengers they might as well have still been sitting in Mariana's. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 30 degrees? I read 26.7. And are you sure you'd know it? You're in an autobus... you're in a funk after dragging your tail on take-off, you're trying to figure out what happened, you find yourself doubting the numbers the other guy's been plugging in, or doubting your machinery, might you have your head down...? Don't you think both those guys would have said they wouldn't ever do that too? How's that old saying go... learn from the mistakes of others, as you'll not live long enough to make them all yourself Saying it could never happen to you doesn't sound to me like you're prepared to deal with your own mistakes very well. Show me the man who doesn't make mistakes and I'll help carry his coffin. Link to comment Share on other sites More sharing options...
DEFCON Posted August 30, 2003 Author Share Posted August 30, 2003 Mitch Break the event in two. Part A is the V speed issue and Part B the glide slope issue. "B" is an event that may be almost forgiveable for many reasons however, "A" is not for as many reasons. ...and yes, we are all very capable of screwing the pooch. Very serious incidents such as this demonstrate the need to maintain appropriate cockpit discipline at all times. Accidents or almost accidents should serve as a learning tool. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 That all sounds right to me. Ironically, I'll bet both those gents would choose to use both parts, and their relationship, as training tools. Cheers. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 I really don't have any business speaking my mind on this, but that all sounds right to me. I reckon both parts A and B, and their relationship, could be used as training tools. Cheers Defcon, Mitch Link to comment Share on other sites More sharing options...
Guest Rob Bos Posted August 30, 2003 Share Posted August 30, 2003 This report only took a year and a bit to be published. When are we going to hear the whole story about Transat's little excursion into the Azores?? Things that make you go...Hmmmmmmmmmm!!!! Link to comment Share on other sites More sharing options...
BoomerPete Posted August 30, 2003 Share Posted August 30, 2003 >>>An unfortunate calamity of errors that they kept from becoming a disaster... They handled it. No need to toss mud their way.<<< Sorry Mitch, but in my opinion a "mistakes happen, coulda happened to anyone" attitude just doesn't cut it for this incident. While mistakes can and do happen to us all, our airmanship and training are there for the specific purpose of trapping and correcting those errors before they have a chance to endanger the passengers, crew or aircraft. In this instance it appears from the report that the quality of airmanship was clearly deficient on two seperate occasions within the same flight resulting in aircraft damage, a partial loss of aircraft control and a significant altitude bust in a very busy terminal area. To dismiss all that with a wave of a hand would be to ignore the question that most needs to be asked: How did two highly experienced and appropriately qualified pilots allow these two very fundamental errors in the aircraft's operation to occur? That question should be provoking some very hard thinking within AC's safety and training departments right now. It's sad to see two guys who were undoubtedly on the whole good pilots end their careers on such a low point (I think many of us have seen this happen at some point to someone - it's never pretty), but that can't stop the acknowledgement that something serious happened, that it reflected very poorly on the airmanship of the individuals involved, and that AC should be looking at what changes in training or SOPs (e.g. reinserting V speeds while pushing back/taxiing) might be need to avoid a future repetition of either of the events. Pete Link to comment Share on other sites More sharing options...
J.O. Posted August 30, 2003 Share Posted August 30, 2003 So right, Rob. Such a shame that the industry as a whole, and Airbus operators in particular, have been prevented from knowing the whole story, and for what reason, God only knows. There's certainly no lack of evidence or witnesses which would preclude a reasonable conclusion as to the cause(s). After this much time without even as much as an interim report, it's hard to avoid smelling a rat (no pun intended). Link to comment Share on other sites More sharing options...
CD Posted August 30, 2003 Share Posted August 30, 2003 There have indeed been interim reports put out by the GPIAA of Portugal (the investigative body responsible for preparing the report on the Air Transat - Azores incident). Unfortunately, I don't understand Portugease so the only links indicating information that has been released that I could find are as follows: Airworthiness Directive 2002-548 R1 ~ A330 Aircraft Fuel leak procedure (ATA 28) http://makeashorterlink.com/?S66D12FB5 AW&ST ~ Air Transat Flameout Probe Winding Down (June 17 2002) http://www.aviationnow.com/content/publication/awst/20020617/aw45.htm YYZ News - Preliminary accident investigation from Portugal of the Air Transat A330 incident last August in Terceira/Azores (January 28, 2002) http://www.interhobbycollectibles.com/YYZ%20News/YYZNewsJanuary282002.htm Link to comment Share on other sites More sharing options...
Moon The Loon Posted August 30, 2003 Share Posted August 30, 2003 With all due respect from someone who is far from perfect, after reading the report, the only incorrect speed re-entered was the V1 speed. The VR and V2 speeds were still correct. Yet the rotation was commenced at V1. I'm having a lot of trouble wrapping my mind around that particular error. Link to comment Share on other sites More sharing options...
Guest regular joe Posted August 30, 2003 Share Posted August 30, 2003 I was wondering the same thing Moon. I do feel sorry for these guys. I know what it's like to make a mistake and then feel like crap later. It's good to discuss it though so as to learn from it. Cheers Link to comment Share on other sites More sharing options...
Guest PortTack Posted August 30, 2003 Share Posted August 30, 2003 "really don't have any business speaking my mind on this" Really? I was telling my Mother a story once about a small problem I had at work flying with an umbearable person. "She offered a well why didn't you...." Doi! Without getting in to the specifics, Mom was right and she wasn't a pilot. At least we're all learning something from this thread and perhaps the fact that the non-flying people can offer insight, points out the differing views just as well. Back to observing....... Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 Now that's different. Mom's always have a right to offer their thoughts on anything and everything. Anyway, as Defcon says, if you take the two events separately, I think I can thoroughly understand how 'B' could have occured. You've all been musing how incredible it is that two highly experienced pilots could have gotten there, and I'd suspect that exact thought was going through their minds as they prepared to turn back. Quite a distraction. As for part 'A'... This paragraph seems to provide a reason the substitution error wasn't caught during the take-off:"In the majority of A330 take-offs, the V1 and VR spread is in the range of one to two knots. Since the spread between the two speeds is usually small, the VR blue circle is most often superimposed by the "1", and the PNF will typically call "V1" and "rotate" in quick succession. In this occurrence, the PNF called "V1" as the speed reference index approached the "1", and called "rotate" immediately after. This prompted the PF to initiate the rotation well below the calculated VR. Since the proper VR speed was inserted in the MCDU, the blue circle indicating the VR was probably off the scale and not visible to the flight crew."Routine builds room for complacency. And it sounds like their display, as a matter of routine, at least partially obscures the Rotate speed? (or does this statement mean it's often totaly obscured - "the VR blue circle is most often superimposed by the " 1 ""?)Is it that hard to imagine not noticing the absence of that blue circle? Is that display situation common to other types as well? Has the design of the display partially contributed to the error? If so, does it require a fix? Mitch Link to comment Share on other sites More sharing options...
handyman Posted August 30, 2003 Share Posted August 30, 2003 Complacency easily creeps in with relaxed operating procedures and although the crew made several errors I believe the true cause of the incident is a weak procedure adopted by the company. I fly for a foreign carrier with British roots and we never have a single pilot enter/modify take-off data in the FMC alone. All numbers are entered and confirmed by both pilots on two FMC's. I believe this simple procedure would have prevented the entire incident. I also believe a poor technique of V speed memory was used by the Captain. I believe in his mind he memorized that Vr was only 1KT higher than V1 and when he heard the incorrect V1 he paused and rotated. He should have waited for the Vr call or quickly looked down and confirmed his own speed. IMHO CPDude Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.