How to crash a 737 using your solid stick and rudder skills

[Gabriel]

My position is twofold:

- This accident would not have happened had the pilots correctly followed the procedures.
- This accident would not have happened have the pilots correctly used solid stick and rudder skills.

And I don't agree that this accident was mainly caused by getthereitis and lack of knowledge of the automation in this plane. Regardless the level of automation and your urge to get there, the reactions that are logical from an airmanship point of view, and required from a procedural point of view, are:

Windshear and a -3000fpm downdraft on final:
Click-click, clack-clack, full power and get the hell otta there.

Persistent stickshaker on short final:
Click-click, clack-clack, reduce AoA just as necessary to silence the stickshaker, full power and get the hell otta there.

Automation is not an issue as soon as click-click-clack-clack.
Getthereitis might be an issue to attempt the approach in the first place, but no pilot will intentionally skip a windshear or stall recovery not to delay the arrival. It would be like saying that because a driver doesn't want to lose time, he will cross a railroad when the gate is closed and he sees the train is in the middle of the crossing.

[Gabriel]

I do not second the motion.

This is going to be one of those filosofical beauties that may detract from the actual discussion of the incident in question.

This philosophical beauty was already taking place in the original thread (as it happens in every thread where there is a "interesting" accident).

But it's Brian's call whether to merge both threads or not and, while I have my preference, I'm ok with either.

[Evan]

Regardless the level of automation and your urge to get there, the reactions that are logical from an airmanship point of view, and required from a procedural point of view, are...

Ok, Mr. Spock, I agree with you there. Now lets look at this from the perspective of a humanoid life form:

- This accident would not have happened had the pilots correctly followed the procedures.
- This accident would not have happened have the pilots correctly used solid stick and rudder skills.

But it happened. Why? My answer is twofold:

- They didn't have procedural training. They didn't even have the FCOM!
- The PIC reacted incorrectly with his solid stick and rudder skills due to poor judgement, overconfidence, flawed situational awareness and getthereitis.

My analysis:

- The first point happened due to company negligence.
- The second point happened due to human nature.
- Human nature is not reliable and can become quite illogical if left to improvise under stress. Procedures exist to defend a pilot from himself.

Getthereitis might be an issue to attempt the approach in the first place...

Exactly.

F/O: Go Around! Go Around!
CPT: No!

If gethereitis had been overridden by practiced procedure, his answer would have been ok, TO/GA and climb. No accident.

That's a fact.

Do you ever wonder why in certain professional sports, althletes learn 'plays' and practice them over and over again? Once in the game, they still need their althleticism to adapt them against an unpredictable adversary. Strategy and athleticism are not opposing forces, they are a winning formula.

[3WE]

- The PIC reacted incorrectly with his solid stick and rudder skills due to poor judgement, overconfidence, flawed situational awareness and getthereitis.

No...you cannot say that.

The pilot reacted incorrectly by using virtually no stick and rudder skills and instead was fighting with and overwhelmed by complex procedural electronic flight management systems...

I'm willing to bet the autopilot disconnect button is pretty much in the same place on the yoke in a 737-200 AND a 737-236A.

I would agree that the CRM was weak andthat he needed better training on the basics and on procedural stuff.

The obnoxious variations in font reflect the importance to this incident.

[Gabriel]

Evan, I am not argueing against that. I agree. But just 2 comments.

You have been mentioning the pilots "solid" stick and rudder skils. Do you have any proof? No, Having Xxxxxx hours in X, Y and Z type are not proofs. Or fo you want to get me started with counter-examples?

While I agree that procedures MUST be taught, trained (so the pilot is familiar with it) and followed, the same could be said about stick and rudder skills, judgment, risk assessment, CRM, etc.

Yes, procedures TEND to be less ambiguous (until you have things like "manage AoA", and there is a bunch of things like that in the procedures, especially when dealing with dynamic situations like stalls, windshears, CFIT escapes, upsets, flight control problems). And most of the times they are more reliable than "brilliant airmanship" alone. That's why they MUST be followed.

Now, understand that se same human nature that can make you not apply the correct stick and rudder skills, or apply them incorrectly, can make you not apply the procedure, or apply it incorrectly.

This sentence:
If gethereitis had been overridden by practiced procedure, his answer would have been ok, TO/GA and climb. No accident.
also applies to this:
If gethereitis had been overridden by sound airmanship, his answer would have been ok, TO/GA and climb. No accident.

And, for the record, and as we discussed recently in another thread, I am not against the procedures. I am all for them. The procedures must be first of all well designed, then well taught (that includes the theory behind them), well practiced, encouraged within a good airline safety culture, and then applied.

It's just that, in many cases, as much as an accident could have been avoided by applying and correctly following the procedure, it could have been avoided by applying and following very basic raw airmanship. So not following the procedure ALONE is not enough to explain the accident.

And, for some reason, the fact that the pilot didn't use quite basic airmanship bothers me more than the fact that he didn't follow the procedure. Like in AF: They didn't follow the procedure, but that doesn't explain why they pulled up like they did and reacted to the stall like they did.

[brianw999]

Rather than merge a 2.5 year old thread I'll simply post Gabriel's links here for your light bedtime reading.

http://avherald.com/h?article=44e48c2a/0000&opt=0

http://caapakistan.com.pk/Upload/SIBReports/SIB-350.pdf

[Evan]

The pilot reacted incorrectly by using virtually no stick and rudder skills and instead was fighting with and overwhelmed by complex procedural electronic flight management systems...

What is a 'procedural' electronic flight management system?

I'm willing to bet the autopilot disconnect button is pretty much in the same place on the yoke in a 737-200 AND a 737-236A.

But the flight deck systems are apparently different enough for the CAA to consider this a causative factor:

It was observed that Boeing 737-200 which was taught during ground schooling and Boeing 737-236A being inducted in Bhoja Air were completely two different variants of Boeing 737 series. In the case of former variant, it is equipped with semi automated flight deck whereas the latter one with automated flight deck. The information with regards to automation capabilities of aircraft which was to be acquired by Bhoja Air, was not in the knowledge of cockpit crew even after the formal ground schooling which also did not cover the variant training of Boeing 737-236A. It is evident that Bhoja Air cockpit crew ground schooling did not cater for the automation of Boeing 737-236A aircraft."

So argue with them, and good luck.

I would agree that the CRM was weak andthat he needed better training on the basics and on procedural stuff.

So, your argument is that a pilot, aged 58, with 10,000+ hours on the -200 and no accidents had weak basic flying skills? I bet he could fly a 737 under the London Bridge. I bet he would too.

What he lacked was CRM and good judgment and that speaks to the culture of the airline. He also seems to have overestimated and misunderstood the capabilities of the autoflight system, which is why he left it on. The report says it most likely disconnected on its own. Procedure dictates that it be switched off when first encountering windshear (first item). He also left the autothust in, contrary to procedure, and that is why he had no thrust. From what I can tell here it appears that he had no trouble with basic skills at all, but didn't understand the limitations of the electronic autoflight systems and so he left them in too long. That combined with disorientation + distraction = game over. Toss procedural expertise into this scenario, you get a benign outcome.

He reacted to stickshaker with the correct instinct for stall, not windshear. How many pilots without procedural training get any experience with extreme LLWS? How does it become instinctive enough to be of any value under stress without procedural training? LLWS is not a basic, it's a supplemental.

The obnoxious variations in font reflect 3WE's perceived importance to this incident.

FIxed. I'll agree to disagree if you agree never to pilot a passenger aircraft.

[ATLcrew]

So, your argument is that a pilot, aged 58, with 10,000+ hours on the -200 and no accidents had weak basic flying skills?

If he did, he wasn't the only one.

[3WE]

So, your argument is that a pilot, aged 58, with 10,000+ hours on the -200 and no accidents had weak basic flying skills?

Nice try, but again, an F on logic.

I don't know what skills he had.

I do see what skills he used. (Ref the title of the thread, written by you).

Dicking with stuff in the cockpit and ignoring the yoke and throttles while you drop 1000 feet on short final in a thunderstorm is not using basic skills.

I also hope you never fly an airliner.

[3WE]

He reacted to stickshaker with the correct instinct for stall, not windshear.

No, he didn't.

Push over and gain 50 knots is not a basic stall recovery technique when you are close to the ground.

...a rule valid for 172s, PA-28's, PA-38's, L-1011s, 737-200's and 737-236A's and maybe more...

Push over and gain 50 knots when you are close to the ground is very crappy stick and rudder skills.

[ATLcrew]

I also hope you never fly an airliner.

If Evan's previous posts are any indication, he not only has no plans to fly an airliner, but he is also not a great fan of flying IN an airliner. It appears the only operation that met with his approval was AA, and even then only their 767 fleet. This would limit his travel choices somewhat.

[Evan]

Dicking with stuff in the cockpit and ignoring the yoke and throttles while you drop 1000 feet on short final in a thunderstorm is using autoflight incorrectly.

QRH procedure would have avoided that.

[3WE]

If Evan's previous posts are any indication, he not only has no plans to fly an airliner, but he is also not a great fan of flying IN an airliner. It appears the only operation that met with his approval was AA, and even then only their 767 fleet. This would limit his travel choices somewhat.

If I ever try to tell ATLcrew how to fly his airliner, please flame me...(or know that it's just ass-hat parlour talk, limited to more obscure aviation fora). And apologies for when I may have sounded that way in the past.

Something makes me suspect that you are one bad-ass at reciting, but more importantly, nailing procedures. I also suspect that you are well aware of the fundamentals behind the procedures.

If you ever face something bad (and I hope you don't), I'd sort of expect you to follow the right procedure and do the fundamental stuff right too.

As opposed to getting confused with procedures and doing wrong fundamental stuff.

Probably something to do with having a good mind and a lot of good, first-world training.

[ATLcrew]

I'm afraid of pilots who think flying these jets can be reduced to a universal set of skills and that the FCOM and QRH are not intended for them. I'm afraid of over-confidence, arrogance and technical ignorance. I'm afraid of complacency. I'm afraid of bad instincts. I'm afraid of startle-factor and getthereitis.

Fortunately, so are all the airlines I fly with quite regularly and their CAA's. They take supplemental training and CRM quite seriously and so do their pilots. Their crews are prepared for the unexpected and well-rehearsed on procedures. And they would never let a pilot transition to a new type without the proper training, let alone without even having copy of the FCOM available.

So if you want to attack me, attack me for that.

Wasn't an attack, I read your earlier posts, and thought you meant the AA 767 thing as stated. Out of curiosity, is there a reason you omitted to actually name these airlines and their respective CAAs, in which you have all that apparently new-found confidence?

[Evan]

Wasn't an attack, I read your earlier posts, and thought you meant the AA 767 thing as stated. Out of curiosity, is there a reason you omitted to actually name these airlines and their respective CAAs, in which you have all that apparently new-found confidence?

AA 767 thing?? New-found confidence?? You've lost me, but you've also lost the thread...

Have you read the posts in this thread and do you have any opinion on the findings of the CAA? Do you understand why they referred to the lack of "automated flight deck variance type training and monitoring requirements" and "non- adherence to Boeing recommended QRH and FCOM remedial actions / procedures due to non-availability of customized aircraft documents" as causitive factors, which I take to mean that basic airmanship alone was not enough to get them through this? Do you disagree that proficiency on procedures would have saved them?