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Tatarstan B735 at Kazan on Nov 17th 2013, crashed on go-around

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  • Tatarstan B735 at Kazan on Nov 17th 2013, crashed on go-around

    Brian,

    I tried to locate the old thread about this accident, but I have had no luck with the search function since the change in the forum engine.
    If you have luck, please join the threads.
    And please report this failure to the admin. Or am I the only one having exactly zero success rate with any search attempted?

    Anyway, back to the accident, we can summarize the MAK findings in:
    - The plane was being flown by a blacksmith, not a pilot.
    - The flight was being operated by a toilet cleaning company, not an airline.
    - Pilots are really dangerous when faced to any slightly non-routine situation, like a go-around (ok, in the AvHerald report in is not stated where the MAK took the sample of pilots from).

    A small sample of the report:

    The captain's not having had primary flight training

    Violation of the principle "Aviate, Navigate, Communicate"

    The MAK performed simulator tests with a number of pilots having them go through a scenario similiar to the accident flight, in particular forcing a go around at low height with the autopilot disconnecting at the initiation of the go-around by pressing the TOGA button. The MAK reported that the vast majority of crews coped well with the scenario but found it difficult to master reporting highly increased stress levels, especially when the pilot monitoring did not provide full assistance. A number of pilots, although the autopilot disconnect aural and visual alerts are very distinct and have high attraction potential, did not catch the fact, that the autopilot had disconnected, several silencing the alerts by pressing the AP disconnect button, a number (about 42% of the pilots tested) not recognizing the alert at all and therefore responding with a substantial delay or not reacting at all. None of the pilots participating in the test was able to answer all questions to the procedures correctly, the MAK reported that 28% even believed the go around was automatic on autopilot despite the AP disconnect alert indicating lack of knowledge and a substantial gap between theoretic knowledge and practical skills.

    Of all pilots participating in the test only one third mastered the go around successfully. Only 28% attempted to achieve a suitable pitch angle after initiating the go around aiming for +15 degrees of nose up, others began to react only between +20 and +37 degrees of nose up attitude and airspeeds as low as 90 KIAS with stick shaker activation. None of the pilots was able to level off at the assigned altitude.

    In a second part of the experiment a test pilot produced a pitch up upset similiar to the accident flight and then let the participating pilot recover the aircraft. None of the pilots took the right decisions and none was able to recover the aircraft. The MAK reported, that after demonstration of the correct upset recovery technics almost all pilots were able to apply the technics and recover the aircraft, suggesting that the result of the experiment was mainly the result of lack of pilot training


    http://avherald.com/h?article=46b9ecbc/0022&opt=0
    Un-f***ing-believable.

    --- 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
    I guess I shouldn't suggest the thought of 'always' maintaining healthy airspeeds, attitudes and power settings.

    (Or is that part of the "primary flight training" they discuss?)
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

    Comment


    • #3
      There is a rather persistent rumor among Russian-speaking pilots that the "Presidential son" who died in the accident was actually at the controls.

      Comment


      • #4
        Originally posted by ATLcrew View Post
        There is a rather persistent rumor among Russian-speaking pilots that the "Presidential son" who died in the accident was actually at the controls.
        That's even more believable than jet fuel fumes exploding in a mostly empty tank.
        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

        Comment


        • #5
          Originally posted by 3WE View Post
          That's even more believable than jet fuel fumes exploding in a mostly empty tank.
          The really sad thing is that it appears that the so-called professionals would have fared no better.

          Comment


          • #6
            Apparently, having basic flying skills* doesn't cut it if you don't understand the on-type automation**. Apparently that can lead to a very flawed situational awareness...

            *The MAK reported the crew had flown the leg to Moscow Domodedovo resulting in a safe landing despite turbulence on final approach and windshear at 60 meters/200 feet AGL and gusting winds on touch down.

            ** the MAK reported that 28% even believed the go around was automatic on autopilot despite the AP disconnect alert indicating lack of knowledge and a substantial gap between theoretic knowledge and practical skills. / Flight crew members being allowed to upgrade to Boeing 737 without satisfying the required qualifications

            Comment


            • #7
              Originally posted by Evan View Post
              ...having basic flying skills* doesn't cut it if you don't understand the on-type automation...
              I know, I'm just sitting on a couch parlour talking...

              BUT:

              Shove power thingies forward.

              CLICK CLACK PADDYWHACK.

              Pull up on big yoke thing (exercising a tiny bit of cowboy airmanship like keeping attitude and speed halfway close to normal climb paramaters).

              Gear up, flaps 15 (or something roughly like that).

              No smoking hole in the ground.

              ...and I don't know $hit about automation.
              Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

              Comment


              • #8
                Originally posted by Evan View Post
                Apparently, having basic flying skills* doesn't cut it if you don't understand the on-type automation**. Apparently that can lead to a very flawed situational awareness...
                This souds more like they had no skills at all...

                Comment


                • #9
                  Originally posted by 3WE View Post
                  I know, I'm just sitting on a couch parlour talking...

                  BUT:

                  Shove power thingies forward.
                  No, no, my friend. it's on autopilot. This is the 737-500. It's a Boeing comrade, not some shitty Yak. It does everything automatically. We just push this button here and everything is ok.

                  That noise? It does that sometimes! Don't worry!

                  Wait.

                  Which way are we pointed?

                  I think up.

                  Ok, maybe we need to push it down. Let's try that....

                  Comment


                  • #10
                    I don't understand how it is possible to make it this far as a pilot and fly airplanes so poorly.

                    Comment


                    • #11
                      Originally posted by Leftseat86 View Post
                      I don't understand how it is possible to make it this far as a pilot and fly airplanes so poorly.
                      You're not alone. A lot of pilots seem to not know how this is possible, as well as operators and CAA's. Accident reports have been trying to tell us for years but these things keep happening because there is a stubborn resistance in the industry to the fact that technically complex pilot-system interfaces have changed the game from a universal skills one to a platform specific one.

                      There was another example of this we discussed recently, where an experienced pilot tried to use the autopilot to escape windshear. What that and this incident have in common is that both pilots OVERESTIMATED the capabilities of the automation—because in both cases they were never trained on the specifics of the automation. They both had basic flying skills. In both cases the bulk of their experience had been on aircraft with relatively primitive analog autopilots and both seemed to assume the digital autopilots could do anything.

                      So, the argument goes, once a pilot gets into an upset and takes over, his basic flying skills should save him. That is the other niave part of the equation. Once a pilot loses his situational awareness, the result of suddenly finding himself in an upset for reasons he doesn't understand, it is very hard to use basic flying skills correctly. Things that are taught become lost in the mental confusion. Somatogravic illusions are trusted over logic. The senses are of little use. A pilot who once trained other pilots on stall recovery will pull up relentlessly without adding power. This is the human mind in confusion.

                      The MOST IMPORTANT thing is to prevent a loss of situational awareness and mental confusion. A pilot with situational awareness and good flying skills will probably recover from an upset. One thing that continually results in a loss of situational awareness is a lack of technical procedure and behavioral knowledge of systems for the specific aircraft type.

                      You can't even begin to discuss flying skills if the pilot has lost his SA.


                      (In this case, the pilot seems to have been taught neither, but clearly had flying skills anyway, though perhaps not upset recovery skills)

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