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TransAsia airplane crashes in Taipei (ATR 72)

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  • #31
    seen on airliners.net:


    local (Chinese) news is now reporting that the pilot "turned off the wrong engine".

    Engine 2 failed (flame-out) at take-off, but pilot mistakenly turned off the healthy engine (engine 1, the good one).

    When they found out their mistake, they tried to restart engine 1, but failed.

    and there is a FDR chart that appears to confirm that:

    http://pbs.twimg.com/media/B9JarHTIAAAgAy3.jpg:large
    plain lines = engine 1, dotted lines = engine 2

    This info made its way to the BBC:

    Officials in Taiwan say they are investigating why both engines on a TransAsia Airlines plane were off when it crashed on Wednesday, killing dozens.


    "Then the other [left] engine was shut down manually. The pilot tried to restart the engines but to no avail."

    see also:

    Aviation Herald - News, Incidents and Accidents in Aviation

    Comment


    • #32
      Originally posted by loupiote View Post
      seen on airliners.net:
      local (Chinese) news is now reporting that the pilot "turned off the wrong engine".

      plain lines = engine 1, dotted lines = engine 2
      Outstanding!

      And the mayor already called the pilot a hero...

      It will be interesting to see what role procedure and CRM played here.

      Comment


      • #33
        Originally posted by Evan View Post
        Outstanding!

        And the mayor already called the pilot a hero...

        It will be interesting to see what role procedure and CRM played here.
        Not the first time this has happened.

        Comment


        • #34
          Originally posted by T.O.G.A. View Post
          Not the first time this has happened.
          Not the second time this has happened either. The engine out procedure is supposed to be covered before takeoff if I'm not mistaken and includes a strict CRM call-out and confirm on the affected engine before taking action. We'll see if that was followed...

          At the end of the FDR, the CL and fuel flow are returned to #1 and it seems that if they only had another 30 seconds...

          Comment


          • #35
            Originally posted by T.O.G.A. View Post
            Not the first time this has happened.
            I don't know about the FCOMQRHPOH for the ATR-72, but I thought there were some very clear, basic, widely applicable principles on how to determine and double confirm the dead engine...rudder inputs, engine instruments, and that this was trained in the simulator a fair bit.

            I guess they were using the memory checklist for an ATR-42.
            Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

            Comment


            • #36
              And Richard Collins is once again redeemed; pilot fails to identify the the failed engine.
              Live, from a grassy knoll somewhere near you.

              Comment


              • #37
                Originally posted by Evan View Post
                Outstanding!

                And the mayor already called the pilot a hero...

                It will be interesting to see what role procedure and CRM played here.
                PM: ENGINE 2 FLAME OUT
                PF: (verifies instruments and other cues) ENGINE 2 FLAME OUT CONFIRMED. I HAVE THE PLANE. I HAVE THE COM.
                PM: YOU HAVE THE PLANE. YOU HAVE THE COM.
                PF: (mayday call)
                PM: ENGINE FAILURE PROCEDURE. (starts to read the engine failure procedure)
                PM: (at a point along the procedure) ENGINE 2 FUEL SHUT OFF.
                PF: (touches the engine 2 fuel shut off lever, button or whatever) ENGINE 2 FUEL SHUT OFF. CONFIRM?
                PM: (verifies that he called the bad engine correctly and that he physically has his hand on the control for that engine) CONFIRM.
                PF: (moves the fuel shut off lever /switch).

                Another good trick is to retard the throttle before shutting off the engine. If you can feel the thrust or see the RPM/torque going down, that's the wrong engine to shut off. Advance the throttle again and look for another engine!

                That is, more or less, what procedures and good CRM call for. Let's see if the CVR produces something similar to this.

                Note that the engine didn't fail at or immediately after rotation. They were at 1000ft, they surely were well above Vmc, the flame out alarm activated for the bad engine, said engine automatically feathered. It was, it seems, not a daring situation where they had to react or die (in fact, it took more than 30 seconds to act on the fuel shut off).

                --- 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


                • #38
                  Originally posted by Gabriel View Post
                  PM: ENGINE 2 FLAME OUT
                  PF: (verifies instruments and other cues) ENGINE 2 FLAME OUT COMPLETE. I HAVE THE PLANE. I HAVE THE COM.
                  PM: YOU HAVE THE PLANE. YOU HAVE THE COM. (mayday call)
                  PM: ENGINE FAILURE PROCEDURE. (starts to read the engine failure procedure)
                  PM: (at a point along the procedure) ENGINE 2 FUEL SHUT OFF.
                  PF: (touches the engine 2 fuel shut off lever, button or whatever) ENGINE 2 FUEL SHUT OFF. CONFIRM?
                  PM: (verifies that he called the bad engine correctly and that he physically has his hand on the control for that engine) CONFIRM.
                  PF: (moves the fuel shut off lever /switch).

                  Another good trick is to retard the throttle before shutting off the engine. If you can feel the thrust or see the RPM/torque going down, that's the wrong engine to shut off. Advance the throttle again and look for another engine!

                  That is, more or less, what procedures and good CRM call for. Let's see if the CVR produces something similar to this.

                  Note that the engine didn't fail at or immediately after rotation. They were at 1000ft, they surely were well above Vmc, the flame out alarm activated for the bad engine, said engine automatically feathered. It was, it seems, not a daring situation where they had to react or die (in fact, it took more than 30 seconds to act on the fuel shut off).
                  No, that's what boggles me. The engine failure sorts itself out automatically in terms of feathering the prop and cutting the fuel flow. There was apparently no fire warning (that would have made the failed engine pretty obvious), so all they need to do is PF: stabilize and PM: take your time, run the QRH and DETERMINE which engine has failed, (which should still be rather obvious) using CRM (we will see if both pilots confirmed the wrong engine). It's not like you have to panic in this situation. It should be well rehearsed to these guys. Maybe there's more to it...

                  But neither of them brought the condition lever on the failed engine back to SO (fuel shut off). Someone retarded the power lever on the good engine. When they figured it out, someone brought the condition lever back to SO on the good engine (now at idle?) to restart it I assume... that's when the fuel flow to the good engine goes to 0.

                  Sounds like a mess of IMPROVISATION.


                  Comment


                  • #39
                    Originally posted by Evan View Post


                    Sounds like a mess of IMPROVISATION.

                    ...or startle factor.
                    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                    Comment


                    • #40
                      Originally posted by Gabriel View Post
                      ...Another good trick is to retard the throttle before shutting off the engine. If you can feel the thrust or see the RPM/torque going down, that's the wrong engine to shut off. Advance the throttle again and look for another engine!...
                      Sounds awfully stick and rudder to me! This isn't a Cessna, you know.
                      Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                      Comment


                      • #41
                        Sounds awfully stick and rudder to me! This isn't a Cessna, you know.
                        But is much better than to shut down the engine. I still wonder what made that crew rush and proceed with an engine shutdown procedure/checklist at this phase of flight! The automation did its job: the propeller feathered, thrust of the working engine increased...They could have ignored any failure checklists an would have survived.

                        Comment


                        • #42
                          Originally posted by georgel View Post
                          But is much better than to shut down the engine. I still wonder what made that crew rush and proceed with an engine shutdown procedure/checklist at this phase of flight! The automation did its job: the propeller feathered, thrust of the working engine increased...They could have ignored any failure checklists an would have survived.
                          He didn't mean it and he wasn't really answering me. It was an ironic and indirect message to another forummate.

                          When your post count reaches 3 digits you will understand

                          --- 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


                          • #43
                            Originally posted by Evan View Post
                            But neither of them brought the condition lever on the failed engine back to SO (fuel shut off). Someone retarded the power lever on the good engine.
                            You are right!!! I had missed that.
                            The bad engine flames out and goes to feather, and the good engine starts to self-increase its torque/FF. But then they start to retard the throttle on the good engine, in several steps (70, 50, 40, 35%) each time the good engine responding correctly in terms of torque and FF. In the middle of these commanded power reductions, they advance the throttle in the bad engine form the position that it had since the take off (some 75%) to about 85%. And then they shut off the fuel of the good engine.

                            I really don't understand it, not even as an improvisation!

                            --- 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


                            • #44
                              Originally posted by Gabriel View Post
                              ..................
                              I really don't understand it, not even as an improvisation!
                              there is a high tech reasoning and wording description for why they shut down the good engine.





                              They f****d up !
                              If it 'ain't broken........ Don't try to mend it !

                              Comment


                              • #45
                                Originally posted by Gabriel View Post
                                You are right!!! I had missed that.
                                The bad engine flames out and goes to feather, and the good engine starts to self-increase its torque/FF. But then they start to retard the throttle on the good engine, in several steps (70, 50, 40, 35%) each time the good engine responding correctly in terms of torque and FF. In the middle of these commanded power reductions, they advance the throttle in the bad engine form the position that it had since the take off (some 75%) to about 85%. And then they shut off the fuel of the good engine.

                                I really don't understand it, not even as an improvisation!
                                I think they may have realized that they had shut down the wrong engine in the very last seconds. The engine flameout master warning had been going off continuously until the last 15 seconds or so when they finally pulled the power on the #2 engine back to FI. That cancels it. Another good indication that you have pulled the wrong engine is if the warning indication remains active.

                                Up til then, they seem convinced that the affected engine is #1. When the CL on the #1 engine goes to SO, that is part of the relight procedure. They are apparently trying to relight the good engine that is still running at flight idle.

                                What a mess. Put this in the 'Ten Easy Ways to Crash a Perfectly Good Airplane' manual. In the chapter titled 'Toss Out Those Scripted Procedures, You Will Always Have Perfect Airmanship Under Pressure!'

                                AFAIK there is no QRH procedure for determining the correct failed engine. That procedure must be trained in the SIM and memorized. I get the feeling it wasn't:

                                Originally posted by AV Herald
                                On Feb 7th 2015 the airline reported, that all 71 flight crew are to undergo additional assessment and training by Taiwan's Civil Aviation Authority over the next 4 days resulting in flight cancellations.

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