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The good, the bad and the ugly of human factors

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  • The good, the bad and the ugly of human factors

    Evan will love this. How to crash a perfectly good A321 on take off and kill everybody onboard, except that you manage to recover and return to land and it all ends in a write-off with no injuries.

    Have you ever seen the "stupid drivers" videos where a driver (not sure why but it is typically a woman) steps on the gas instead of the brake and ends up in the fountain or crashing against the parking lot gate? Well, that exact thing caused a deadly accident in the Elementary school where my children attended, killing a parent and injuring 3 young students, one of them seriously.

    American Airlines flight 300 seem to have been something similar

    Aviation Herald - News, Incidents and Accidents in Aviation

    https://data.ntsb.gov/carol-repgen/a...port/99240/pdf

    Go to https://curiositystream.thld.co/mentourpilot_0822 and use code MENTOURPILOT to save 25% off today, that’s only $14.99 a year. Thanks to Curiosity Strea...


    In this accident, the pilot made increasing left rudder pedal inputs upon rotation, reaching full deflection, when apparently he intended to make right inputs or neutralize the left inputs he had ben making to counteract the very average crosswind from the right. That created a cross-over situation that induced a left roll that could not be counteracted eve with both the pilot flying and the pilot monitoring making DUAL INPUTs with the sidestick keeping both at full right deflection. The bank angle reached a max angle of 37 degrees when the left main landing gear was still on the ground or just becoming off.

    The pilots didn't realize it, but the wing scraped the runway and it hit several runway edge lights and a runway sign (part of which remained embedded in the wing). The wing had an parts permanent bend of over 6 inches, which is what ultimately caused the writing off.

    And here is where the good CRM starts.

    Both pilots were very shaken. Both pilots said they thought that they were going to roll over and crash-burn-die. Both pilots said they would need some time off after that, but they were still continuing with the departure procedure. After the plane had stabilized in the climb the cabin crew called the flight crew asking what on Earth had been that. The first officer suggested subtly first, and then insisted, that they should consider turning back. The captain, who had been the pilot flying, had an introspective self-assessment moment and concluded that the fact that he had not even considered that option was evidence that he was in a mental state that made him not fit to fly. He decided to return and transfer PF duties to the first officer. The cabin crew contacted them again and said that a pax reported that a wing was damaged, and that she went and looked and yes, it is damaged indeed. The pilots advised ATC who then performed a runway inspection for debris.

    They returned to the departure airport and the landing was uneventful despite the plane being already damaged beyond economic repair.

    The airline made an internal investigation checking FOQUA data for hundreds of thousands of take offs and found that the rudder inputs made in the other flights had been much smaller than in this flight, even in cases with higher crosswind, supporting NTSB's and Airbus's findings that the plane just responded nominally to pilot-made control inputs.

    The pilots collaborated with the investigation (both NTSB's and the airline's).

    The airline provided additional crosswind training to the pilots involved, and apparently they are flying again.

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    --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
    --- Defend what you say with arguments, not by imposing your credentials ---

  • #2
    Well, first of all, it's nice to see that Mentour Pilot guy got picked up and funded. So now we get some nice 3D visualizations (creepy meta-humans aside). That said, I can't help but wonder if he's not also courting a job at AA.

    I could ask: what is the deal with AA and rudder training, but I will chalk that up to coincidence. I don't think the PF here intended to make that large rudder input.

    Now... Mentour Pilot can't seem to commend this crew enough for their exceptional CRM. I question that. The very first thing that should have been done after AVIATE (stabilize the thing) and NAVIGATE (remain on the planned departure heading and possibly stop the climb), is COMMUNICATE. And any sort of unexplained flight control issue that results in that level of upset DEMANDS a return. I realize there was a shock factor here but also maybe a denial factor. It actually takes an FA to ask whether the flight control anomaly might recur during the remainder of the flight.

    (Sidebar: How does BoeingBobby stand on FA's drilling pilots about piloting issues over the interphone? Oh, right, boxes don't need them anyhow.)

    So, yes, the gravity sinks in after a very wishy-washy discussion in which the PIC can't seem to make a command decision (due to shock?). He was probably in shock. Maybe they both were. Explainable but not exactly commendable CRM. Meanwhile, the tower is clueless and 15 following flights may have narrowly avoided puncturing a fuel tank with tire shrapnel.

    I didn't have time to read the NTSB report tonight. I wonder if the PF's seat position was a factor.

    ---------------

    Question: Are ANY rudder inputs needed during crosswind takeoffs on the A321 in RWY mode? Is it an autoflight mode or only an FD mode? I've read that this lateral mode remains poorly understood even by some Airbus pilots.

    Comment


    • #3
      Originally posted by Evan View Post
      Question: Are ANY rudder inputs needed during crosswind takeoffs on the A321 in RWY mode? Is it an autoflight mode or only an FD mode? I've read that this lateral mode remains poorly understood even by some Airbus pilots.
      What? I have never heard of that. The rudder pedals are a directional control (not lateral) and the rudder is not FBW. Plus, there are 4 inputs to the rudder: Pedals, trim, autocoordination and yaw damper and, as far as I know, autocoordination and yaw damper are inactive with the plane on the ground. Given all that, yes, rudder inputs would be needed during take off to counteract whathervanining.

      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
      --- Defend what you say with arguments, not by imposing your credentials ---

      Comment


      • #4
        Originally posted by Gabriel View Post

        What? I have never heard of that. The rudder pedals are a directional control (not lateral) and the rudder is not FBW. Plus, there are 4 inputs to the rudder: Pedals, trim, autocoordination and yaw damper and, as far as I know, autocoordination and yaw damper are inactive with the plane on the ground. Given all that, yes, rudder inputs would be needed during take off to counteract whathervanining.
        RWY is listed as an AP/FD lateral mode in the FCOM (which, of course, means directional on the ground). The language is that it “guides” the aircraft along the runway ILS heading during takeoff. A yaw bar appears on the PFD. I’m unsure about whether it is AP or only FD because I see no reason why it can’t function as AP (and plenty of reason why it should, such as this incident) and the language ‘guides’ rather than ‘provides guidance’.

        Comment


        • #5
          From what I’ve gathered, the autopilot rollout mode is limited to a 10kt crosswind component in the A321, so the AP might not have enough rudder authority to maintain centerline in higher crosswind conditions. Therefore RWY probably requires pilot inputs on the rudder. Still hoping for some clarity on this.

          Comment


          • #6
            Autopilot in yaw via rudder trim has 20-25deg of deflection authority but rudder rate is only 1deg per second, so good enough for steady crosswinds but not strong gusts. This explains the crosswind limit for ROLLOUT. Any autopilot capability for RWY would have the same limitation. In any case, these modes require pilots to be alert and ready to intervene: tools, not pilotless flight.

            Comment


            • #7
              I believe the reason RWY is only a FD mode is because the AP cannot be engaged above the MCT detent. When landing, the thrust is at IDLE so the autopilot can control in ROLLOUT.

              Anyway, as it pertains to this incident, with RWY active, the FD displays a yaw bar (highlighted in green) on the PFD for rudder guidance. Was the PF aware of this function?

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              Comment


              • #8
                Originally posted by Evan View Post
                ---------------

                Question: Are ANY rudder inputs needed during crosswind takeoffs on the A321 in RWY mode? Is it an autoflight mode or only an FD mode? I've read that this lateral mode remains poorly understood even by some Airbus pilots.
                It is an FD mode only, and it changes to RWY TRK once weight comes off wheels. Rudder is definitely required during crosswind takeoffs but not more or less so than on anything else I've flown.

                Comment


                • #9
                  Originally posted by Evan View Post
                  I believe the reason RWY is only a FD mode is because the AP cannot be engaged above the MCT detent. When landing, the thrust is at IDLE so the autopilot can control in ROLLOUT.

                  Anyway, as it pertains to this incident, with RWY active, the FD displays a yaw bar (highlighted in green) on the PFD for rudder guidance. Was the PF aware of this function?

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                  Why should the PF be looking at the Washington Monument (that's what we sidestick jockeys call that "yaw bar") during takeoff? In fact, why should he be looking at the PFD at all? Where should his eyes be?

                  Comment


                  • #10
                    Originally posted by ATLcrew View Post
                    In fact, why should he be looking at the PFD at all? Where should his eyes be?
                    The QRH, right?
                    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

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                    • #11
                      Originally posted by ATLcrew View Post

                      Why should the PF be looking at the Washington Monument (that's what we sidestick jockeys call that "yaw bar") during takeoff? In fact, why should he be looking at the PFD at all? Where should his eyes be?
                      Typically, I would agree. But this pilot expressed his confusion in needing much more rudder than expected (and later, his disdain in wondering what this crazy French airplane was thinking). At that point, I think a glance at the FD guidance might have been helpful. I mean, that IS what it’s there for, isn’t it? Or is it just for zero-visibility takeoffs?

                      Comment


                      • #12
                        Originally posted by Evan View Post
                        ***I think a glance at the FD guidance might have been helpful. I mean, that IS what it’s there for, isn’t it?
                        A glance is great, and while I know very little of the type-specific procedures of the A-321-236A, I’m thinking the gross fundamental is to primarily (that’s an important not_absolute term) focus out the windows where one might reasonably detect deviations from the center and even 5% banks, and make somewhat earlier CRM inputs, and save an expensive aeroplanie from the parts department, I mean, that is why they put windows in cockpits, isn’t it? Or are they only there so the pilots can buy stylish, mirrored RayBans?
                        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                        Comment


                        • #13
                          Originally posted by Evan View Post

                          Typically, I would agree. But this pilot expressed his confusion in needing much more rudder than expected (and later, his disdain in wondering what this crazy French airplane was thinking). At that point, I think a glance at the FD guidance might have been helpful. I mean, that IS what it’s there for, isn’t it? Or is it just for zero-visibility takeoffs?
                          I don't think such a glance would have helped much. At best it would have told he was yawing, not WHY he was yawing, so probably only added to the confusion.

                          Comment


                          • #14
                            Originally posted by ATLcrew View Post

                            I don't think such a glance would have helped much. At best it would have told he was yawing, not WHY he was yawing, so probably only added to the confusion.
                            I mean before the magnificent 28 degree left rudder input that caused the large yaw. If he was confused about how much rudder was needed to maintain centerline, wouldn't it be better to go to the FD guidance than just shrug and add much more than one would think necessary?

                            Gabriel could be right. This might have been a left-foot-in-right-foot-out mental error, but such things tend to come during some moment of confusion or frustration. RWY seems like a good way to prevent that sort of thing.

                            Comment


                            • #15
                              Originally posted by 3WE View Post
                              I mean, that is why they put windows in cockpits, isn’t it? Or are they only there so the pilots can buy stylish, mirrored RayBans?
                              My policy would be: look out the windows; if things don't seem right, check your primary guidance instruments. And, if that still doesn't set you straight, try it without the stylish Ray Bans.

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