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TransAsia airplane crashes in Taipei (ATR 72)

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  • #46
    Originally posted by Evan View Post
    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:
    all you need to know.

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    • #47
      Originally posted by TeeVee View Post
      There is a specific action, who is often overlooked, to prevent shutting down the wrong engine and give you one last chance to not f... up in the stressful moment.

      The QRH said : IF no Autofeather
      - Affected PL ----- reduce to 48 degree angle( 48 to reduce drag below that you will be in the Beta Range )
      - Affected CL ----FTR THEN Fuel Shut Off

      THEN : is the most important word in that check list. As a flying pilot never call FTR then Fuel Shut OFF in one sentence.
      First call FTR and leave it there and check you are still climbing and look around that everything is normal, and THEN when you are sure that you are climbing out call for Fuel Shut Off. By doing that you will save your day because if you have call for the wrong engine you still have a chance to bring back the CL to max rpm and the PL to the ramp.
      Once you go to Fuel Shut Off It is over, at 400 feet there is no way you have time to restart that engine.
      It may seemed obvious but I have seen so many time in the Sim, people just spit out the call out and the Non Flying pilot going from FTR to Fuel Shut Off in nearly one motion. ( TAKE YOUR TIME )
      Add to this that the PM must move the CL AFTER the PF has confirmed that it is the correct one. Both pilots could be wrong, but that's hard to imagine.

      ( TAKE YOUR TIME ): There was plenty of time here. The Pprune link concerns engine failure on takeoff and below 400', which is a critical situation. But TransAir was at 1200'. All the PF needed to do was reduce the climb and stabilize on the flight path to allow the the crew plenty of time to assess and confirm the situation and take QRH actions to either relight or shut down the affected engine. Worst case scenario: an eventless return.

      The QRH does list moving the CL to FTR and THEN SO as sequential actions. It would be easy for an untrained pilot to see this as FTR, then immediate SO without pausing to gauge the effect. Once the remaining engine CL is moved to SO, you're in a critical situation at 1200'.

      But in the first place, nothing gets moved without the PF's confirmation.

      Comment


      • #48
        Somewhere, there's a great video. I could not find it on Youtube.

        Some guys were filming a simulator session...the filming was the objective and it may have even been a practice run at filming.

        The pilots were not operating with their "game faces" on.

        Just after lift off an engine tanks...the PM blurts out the memory checklist and proceeds to secure things.

        ...You then hear the pilot flying saying, "no, no, no", then someone says "oh poop", there's a crashing noise, laughter and the comment that that's how it happens.

        Sure, their experience is not valid because they were half-ass operating the simulator...

        ...but switch 'lax attention to details' with that new term "startle factor" and the human factors and how the brain works with procedures, fundamentals, comprehension, short time intervals, stress, and mundane repetitive tasks and it's actually kind of scary.
        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

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        • #49
          Originally posted by 3WE View Post
          Somewhere, there's a great video. I could not find it on Youtube.
          If it's the same video that I saw, then what happened is that one guy had pre-programmed an engine failure at say 200 ft and the other guy had planned simulate an engine failure at V1 or Vr, without them knowing each other's plan.

          When they reach say Vr, the guy that had planned so cuts the engine and say "engine failure". The other guy starts to laugh at once because that the other engine was about to fail too.

          The rest is history.

          --- 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


          • #50
            Here it is.
            This was an unintentional dual engine failure! Marty had set the right engine to fail at 80 knots (about 5 knots after V1) and Ken, not knowing the failure w...


            Actually, I think that "pause" button would be a great addition modern airliners!

            --- 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


            • #51
              Originally posted by Gabriel View Post
              Here it is.
              This was an unintentional dual engine failure! Marty had set the right engine to fail at 80 knots (about 5 knots after V1) and Ken, not knowing the failure w...


              Actually, I think that "pause" button would be a great addition modern airliners!
              NO!

              That is not the video- I pretty clearly remember "no, no no!" and a crashing sound.

              Enjoyed the video though, nice little turn as the engine dies...
              Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

              Comment


              • #52
                Originally posted by brianw999 View Post
                there is a high tech reasoning and wording description for why they shut down the good engine.





                They f****d up !
                There is a very good book Blink by G.Malcolm. He analysis decisions made in stressful situations. The long and the short of it is that up to a certain level of adrenaline our brains work faster and are able to make better decisions. But over that level our higher reasoning centers shut down and we basically go back to being a reptile.

                Comment


                • #53
                  Originally posted by Evan View Post
                  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:
                  Ok, so this is not specific of the ATR-72-RQZ MK4 V 2.0.1.204 QRH FCOM 2nd eddition. But it could have saved a bunch of lives.

                  John King from King Schools explains engine-out procedures on twin-engine airplanes using Beechcraft Duchess.Video is featured in Microsoft Flight Simulator ...

                  --- 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


                  • #54
                    Originally posted by 3WE View Post
                    Enjoyed the video though, nice little turn as the engine dies...
                    I wish they had not stopped the simulation when the second engine failed.

                    --- 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


                    • #55
                      Originally posted by Gabriel View Post
                      Ok, so this is not specific of the ATR-72-RQZ MK4 V 2.0.1.204 QRH FCOM 2nd eddition. But it could have saved a bunch of lives.

                      https://www.youtube.com/watch?v=tVcuDHvtcMQ
                      Young John McCain is right, don't think too fast, and I like his "raise the dead" memory item (I wish they could do that for the 53 souls that died here). But that procedure is definitely not for the ATR-anything. The key difference between a single-pilot reaction and a dual-pilot procedure is that the pilot not flying is moving the condition lever and possibly the throttle as well but has no direct feel for the effect. Therefore he has to get pilot flying confirmation on the dead engine for each lever movement BEFORE he moves them and must give the pilot flying a moment to verify that the feathered prop has had the expected effect before shutting off the fuel flow. That's all CRM.

                      Comment


                      • #56
                        Originally posted by Evan View Post
                        Young John McCain is right, don't think too fast, and I like his "raise the dead" memory item (I wish they could do that for the 53 souls that died here). But that procedure is definitely not for the ATR-anything. The key difference between a single-pilot reaction and a dual-pilot procedure is that the pilot not flying is moving the condition lever and possibly the throttle as well but has no direct feel for the effect. Therefore he has to get pilot flying confirmation on the dead engine for each lever movement BEFORE he moves them and must give the pilot flying a moment to verify that the feathered prop has had the expected effect before shutting off the fuel flow. That's all CRM.
                        For what it's worth, I think that the procedure should be that the pilot flying retards the power lever (throttle) on the engine that is suspected bad.

                        --- 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


                        • #57
                          Originally posted by Gabriel View Post
                          For what it's worth, I think that the procedure should be that the pilot flying retards the power lever (throttle) on the engine that is suspected bad.
                          I've seen it both ways. The PNF is always moving the CL, but one procedure I read has the PNF placing his hand on the PL, then the PF confirms it, and the the PNF pulls it back. Same with the CL. The QRH I have has the PF moving the PL, but there is no other CRM instruction on the QRH.

                          I don't know, but it seems like in this case both pilots had it wrong. I'm not sure how that can happen with engine gauges right there on the SD and the obvious performance feedback of cutting the live engine...

                          It's bordering on that AF447 level of bizarre pilot error.

                          Comment


                          • #58
                            Originally posted by Evan View Post
                            I'It's bordering on that AF447 level of bizarre pilot error.
                            Very poor comparison, Evan.

                            The world is not black and white. Pilot makes a mistake does not equal Pilot makes a mistake for all crashes.

                            AF

                            35,000+ of feet to work with and a plane in perfect mechanical shape that is flying fat dumb and happy.

                            We choose a very wrong thing to do, that goes against all fundamentals (and the FCOMQRHPOH for the A330-104.7n) and we do that wrong thing for 6 minutes straight.

                            Yes, we could simply keep flying it using our best stick and rudder skills (or maybe even average stick and rudder skills)!

                            VS.

                            TA

                            1000 ft, a very broken plane that takes a very significant effort to keep flying straight, at a phase of flight that's halfway critical anyway, with critical management needed to not make an uncommanded turn, not stall, and which diligence demands that you quickly be sure the big ass prop isn't dragging you down nor is the engine on fire and burning through the wing and plan to get the hell back to the field expeditiously in case Hui Chuan Jeta and Sum Ting Wong were on the fuel truck.

                            By the way, keeping the thing straight and dead on speed for a painfully slow climb, this requires top notch stick and rudder skills.

                            ...all with a relatively small margin for error and very little time to screw around.

                            ...and you make one little f-up while actually executing the FCOMQRH memory checklist and being sure you don't accidentlaly pull the wrong engine like several good pilots have done before you.

                            Indeed, they both share the "Startle factor" but one incident gives you all day to work it out as long as you don't do stupid things for 6 minutes straight...including time to right wrongs if you make a brief screw up...

                            ...the other gives you much less time to act, and unfortunately no time fix things in case you have a brief brain fart.
                            Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                            Comment


                            • #59
                              Originally posted by Gabriel View Post
                              Ok, so this is not specific of the ATR-72-RQZ MK4 V 2.0.1.204 QRH FCOM 2nd eddition. But it could have saved a bunch of lives.

                              https://www.youtube.com/watch?v=tVcuDHvtcMQ
                              How many times do you need it explained to you?...this crash wasn't a Cessna...
                              (or a Beechcraft)

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

                              Comment


                              • #60
                                Originally posted by 3WE View Post

                                Indeed, they both share the "Startle factor" but one incident gives you all day to work it out as long as you don't do stupid things for 6 minutes straight...including time to right wrongs if you make a brief screw up...

                                ...the other gives you much less time to act, and unfortunately no time fix things in case you have a brief brain fart.
                                Both required them to do nothing but fly the plane level within the envelope and go through the QRH in a calm, professional* manner. Neither was a situation where a quick panic reaction was needed to do that. Time was not of the essence in either case. Both most likely were stellar examples of confused situational awareness brought on by poor training (weak safety culture) and unfamiliarity with abnormal ops procedure.

                                *A professional is someone who has the professional training needed to do their job on a bad day.

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