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Thread: Plane with 71 on board goes missing after taking off from Moscow

  1. #61
    Senior Member Gabriel's Avatar
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    Quote Originally Posted by BoeingBobby View Post
    I can't win for loosing with you Gabe, I think sometimes there are nuances that are lost in the translation. Here it is right out of the manual. This is an immediate recall item. No time for pulling out books. Pull out the books after you are up, away and safe.

    Attachment 13921
    I don't know what does that have to do with my previous comment.
    And I don't know what translation are you talking about, but let me clarify:

    Evan: The memory items (or immediate recall items) for UAS at high altitude in the A330 are 1) AP/AT/FD disconnect, 2) thrust: CLB, 3) pitch: 5 deg nose up. If the pilot does anything that is a hair different than that it is unacceptable and I don't care about what is reasonable or what the pilot likes or about generally safe pitch and power settings. (and, by the way, I agree with Evan)

    BoingBobby: I agree with you. In a situation such as that, wings level, pitch 5 - 10 degrees ( I like 10 in the 74) and MAX CONTINUOUS THRUST! Just a little less pitch than for wind-shear.

    Do you see the contrast?

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  2. #62
    Senior Member brianw999's Avatar
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    Ho Hum ! Time I think for a favourite video of mine. For the old time regulars here you can go make a coffee now because yes, it’s “Children of the Magenta” time. For the newbies, watch this all and take especial notice of the comment at 24.10.

    https://youtu.be/pN41LvuSz10
    If it 'ain't broken........ Don't try to mend it !


  3. #63
    Senior Member BoeingBobby's Avatar
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    Quote Originally Posted by Evan View Post
    The link is to a Ground Proximity Warning procedure. Or did you post this just as an example of an immediate recall item?

    Yes

  4. #64
    Senior Member Gabriel's Avatar
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    Quote Originally Posted by brianw999 View Post
    Ho Hum ! Time I think for a favourite video of mine. For the old time regulars here you can go make a coffee now because yes, it’s “Children of the Magenta” time. For the newbies, watch this all and take especial notice of the comment at 24.10.

    https://youtu.be/pN41LvuSz10
    And, more importantly, 20:05 to 20:40.

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  5. #65
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    If the pilot does anything that is a hair different than that it is unacceptable and I don't care about what is reasonable or what the pilot likes or about generally safe pitch and power settings. (and, by the way, I agree with Evan)
    I don't agree with that. I'm not advocating some sort of rigidly precise execution (where did you get that idea... oh, right, 3WE). It might not even be possible in turbulence. Look, the idea—for the millionth time—behind immediate recall items is to have an immediate reaction trained into the minds of pilots that assures that the plane will remain stabilized within the envelope until they have had ample time to gather their situational awareness and made the appropriate decisions regarding all that awareness. As long as they have the memorized procedure in mind when they execute it with a small margin of error (which it accomodates), that's a win as far as I'm concerned. Saying things like "anything that is a hair different" makes it sound oppressive. And this 'procedures are oppressive' mentality is at the heart of the problem.

  6. #66
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    And while following the procedure is the best and only acceptable way to live through UAS, it is by no means the only one.
    It is the only acceptable one.

    If I had an airline and found that one of my pilots had lost speeds, failed to execute the established procedure (where nothing prevented it) and rode it out without incident, that pilot is going to be reprimanded. The reasons for procedures go beyond what is needed to control the plane. They come from everything that has been learned from accident investigations and all that knowledge is worthless if pilots don't value it. Human factors, complex systems interdependencies, stealth factors, uneven pilot proficiency, these are the hidden dangers.

    Again, following the procedure is the best and only acceptable option, just not the only viable one.
    Here is the immediate recall procedure at my airline:

    1) Execute well-trained and memorized procedure > stabilize > CRM > whatever is viable.

    2) Where well-trained and memorized procedures are not available (or forgotten), then skip to whatever is viable.

    Keeping in mind that 'viable' is a subjective assessment subject to grievious human error.

    I have a little more sympathy for the PNF who, by the design of the Airbus control system, had no feedback on what control inputs the PF was doing
    Seriously? You don't consider the PFD feedback? I agree that the sidestick is a disadvantage here, but come on... And during the botched stall recovery the plane was responding to those inputs, but the focus needs to be on not ever getting to that point.

    My point is that I would not trust a pilot with following any specific procedure for any specific condition in any specific airplane type if they don't give me confidence that they are capable to use their general workmanship to do better than what AF did. Or Colgan. Or Pinnacle.
    But what if they did prove themselves capable, as these pilots almost certainly did to become certified and employed by AIr France? Once again Gabriel, you are discounting human factors, the reason we have to have these procedures in the first place.

  7. #67
    Senior Member Evan's Avatar
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    Quote Originally Posted by Evan View Post
    1) Execute well-trained and memorized procedure > stabilize > CRM > whatever is viable.
    Another way to look at this is AVIATE > COMMUNICATE (CRM) > AVIATE > NAVIGATE > COMMUNICATE (RADIOS)

    Where the first AVIATE stabilizes you enough to safely COMMUNICATE (CRM) so that the second AVIATE is done with the correct situational awareness.

  8. #68
    Senior Member Gabriel's Avatar
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    Evan, 2 yes/no questions:

    1) Do you agree that we need to ensure, to the extent possible, that we have good pilot material that understands well the generalities of airmanship before teaching him specific procedures for specific circumstances in specific types?
    2) Do you agree that a pilot that meets 1) and gets so confused / startled / disoriented / paralyzed / panicked to react to UAS (or to any other abnormal circumstance) at cruise by pulling a 1.5G, 7000 fpm, 2000 ft climb and when the stall warning activates, pull up again and keep pulling up all the way to the ground (or sea), may (vs will) fail to make a correct UAS diagnosis in the first place and then fail to recall or apply the UAS memory items correctly even if said procedure was taught, demonstrated and trained? (else you are proposing that the startled pilot will fail to fly the plane reasonably straight and level will not fail to recognize a specific situation and apply a specific procedure)

    If you reply YES to both questions, then we have nothing else to discuss.
    If you reply NO to one or more of those questions, then we have nothing else to discuss (but for totally different reasons).

    In any event, we have nothing else to discuss. I am done here.

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  9. #69
    Senior Member Evan's Avatar
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    Quote Originally Posted by Gabriel View Post
    Evan, 2 yes/no questions:

    1) Do you agree that we need to ensure, to the extent possible, that we have good pilot material that understands well the generalities of airmanship before teaching him specific procedures for specific circumstances in specific types?
    2) Do you agree that a pilot that meets 1) and gets so confused / startled / disoriented / paralyzed / panicked to react to UAS (or to any other abnormal circumstance) at cruise by pulling a 1.5G, 7000 fpm, 2000 ft climb and when the stall warning activates, pull up again and keep pulling up all the way to the ground (or sea), may (vs will) fail to make a correct UAS diagnosis in the first place and then fail to recall or apply the UAS memory items correctly even if said procedure was taught, demonstrated and trained? (else you are proposing that the startled pilot will fail to fly the plane reasonably straight and level will not fail to recognize a specific situation and apply a specific procedure)

    If you reply YES to both questions, then we have nothing else to discuss.
    If you reply NO to one or more of those questions, then we have nothing else to discuss (but for totally different reasons).

    In any event, we have nothing else to discuss. I am done here.
    1) You know I do.

    2) That's gotta be a no, BECAUSE even those who have a poor understanding of the concepts and dynamics of aerodynamics and piloting may still be trained like monkeys to RELIABLY react in a certain way to a given circumstance. If, at that moment, the brain lacks a trained response, the brain will improvise, as it did on that fateful day, and many other fateful days. Again, the procedures are not there to inhibit stellar pilots with perfect situational awareness, they are there to protect us all from pilots like the one who doomed AF447. But in order for that to happen, ALL pilots have to follow them.

    Here's my question to you: when someone suddenly pushes you from behind and, completely disoriented, you fall forward, do you have to think about raising your arms in front of you?

    These immediate recall procedures are very simple and designed to be almost that instinctive.

    Sudden decompression! Boom! Oxygen mask! Pax Oxygen ON! Now you have time to think, for CRM. And you didn't go to the QRH in a state of hypoxia.

    Ground Proximity! Advance to climb thrust! Establish 20° pitch (don't stall)! Now you have time to think, for CRM. And you didn't add pitch while spacing out the thrust levers.

    UAS! Level wings! Fly 5* pitch! Move the thrust levers to climb (or out of the detent and back in if you're driving the bus)! Kill the FD's! Now you have time to think, for CRM. And you didn't fall for the instinct to climb above the weather (even though it seemed viable).

    If only they were taught, practiced and respected to the extent needed. What gets in the way, I think I'm finding out...

  10. #70
    Senior Member 3WE's Avatar
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    Quote Originally Posted by Evan
    ... my question to you: when someone suddenly pushes you from behind and, completely disoriented, you fall forward, do you have to think about raising your arms in front of you?
    You can’t stand it when we suggest that it’s ok for the elbow to hinge parallel to the the body- because some procedure says your elbows must hinge out and away from the body.

    In the meantime we ask why Bonin deliberately landed teeth first while he worries which way to fold toilet paper when wiping front to back and wondering why his 2-ft thick anti push suit failed.
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

  11. #71
    Senior Member Evan's Avatar
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    Quote Originally Posted by 3WE View Post
    You can’t stand it... etc., etc.
    I'm also done try to arguing this here, except to repeat this simple and obvious truth:

    The procedures are not there to inhibit stellar pilots with perfect situational awareness; they are there to protect us all from pilots like the one who doomed AF447. But in order for that to happen, ALL pilots have to learn them, practice them and follow them.

  12. #72
    Member ATLcrew's Avatar
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    Quote Originally Posted by Gabriel View Post
    In any event, we have nothing else to discuss. I am done here.
    I doubt that somehow...

  13. #73
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    Quote Originally Posted by ATLcrew View Post
    I doubt that somehow...
    Me too!

  14. #74
    Senior Member Gabriel's Avatar
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    Quote Originally Posted by ATLcrew View Post
    I doubt that somehow...
    I meant for this specific discussion with Evan.

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  15. #75
    Senior Member 3WE's Avatar
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    Quote Originally Posted by Evan View Post
    ***(where did you get that idea... oh, right, 3WE)***
    I think I actually taught Gabriel something...once...

    But the concept that you could select a familiar, robust power setting and attitude and maintain desired, fat, dumb and happy horizontal and vertical speeds...and that sub-par pilots might remember that from 172 school since it amazingly ALSO applies to an A330...

    ...he learned that elsewhere...

    Probably some CFI or textbook or something.
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

  16. #76
    Member orangehuggy's Avatar
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    the final report came out, can we discuss?
    moving quickly in air

  17. #77
    Senior Member Gabriel's Avatar
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    The report is in Russian, which few of the forum members understand.

    AvHerald translated the causal factors part of the report:

    http://avherald.com/h?article=4b4cb236/0000&opt=1

    Not much to discuss... I highlighted some (in my opinion) key parts.

    The report concludes the probable causes of the crash were:

    The crash of the An-148-100B RA-61704 was caused by erroneous actions of the crew during departure in instrumental weather conditions in relation to unreliable indications of the air speed caused by the icing (ice blockage) of all three dynamic probes of the pitot system, which led to the loss of control over the parameters of the aircraft's flight resulting in a dive and collision with the ground.

    The accident falls into the category loss of control in flight (LOC-I).

    The investigation revealed systemic deficiencies in the assessment of risk as well as risk control, the failure of the airline's flight safety management system as well as lack of supervision of training of flight crew by aviation authorities at all levels, which led to the issuances of certificates to aviation personnel and crew, who did not fully qualify.

    The most likely contributing factors were:

    - Crew's rush in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" time;

    - The crew's failure to turn on the heating of the pitot probes before take-off and non-compliance with/non-execution of the "BEFORE TAKEOFF" checklist, which provides for this action.

    - Design features of the An-148 aircraft which restrict the duration of pitot heating while on the ground, which required to move the items pitot heating into the "BEFORE TAKEOFF" checklist rather than the "ENGINE START" checklist, which creates additional risks of missing these operations.

    - Systematic failure by airline crews to comply with the principle of "dark cockpits" and the requirements of the pitot system, which contributed to the "habit" of taking off despite the presence of emergency and warning messages on the electronic indication and alarm system (KISS) and failing to identify the fact that the heating of the pitot probes is not included. Six warning messages were displayed on KISS before departure for the accident flight including three relating to the absence of pitot probes' heating.

    - Design features of the An-148 aircraft which disabled removal of KISS messages related to system defects which have been deferred under MEL.

    - Low safety culture within the airline which led to non-entries of inflight problems into the tech logs as well as performing flights with issues that were neither rectified nor deferred with the relevant fault messages displayed at KISS and failure to identify the KISS messages and analyse them to identify lack of pitot probe heating.

    - The crew's unpreparedness when the ALARM "SPEED DISAGREE" was issued because of lack of theoretical training, lack of according simulator training and lack of according training on aircraft. This resulted in the failure to follow the proper procedures once the alarm was raised.

    - Lack of supervision by the Civil Aviation Authority in certifying the flight simulator according to Russian Air Code

    - Approval of the An-148 flight simulator without consideration to their ability to reproduce special cases in flight as stipulated in Russian Air Code and FAR-128.

    - Lack of specific guidance on values of flight parameters that must be sustained in case of "SPEED DISAGREE" alarm respective lack of an unreliable airspeed procedure.

    - Increased psycho-emotional stress by flight crew members during the final stages of flight due to the inability to understand the speed fluctuations. As result the captain suffered "tunnel view" on his speed indications for speed control rather than considering all flight parameters.

    - Insufficient training of flight crew with respect to human factors, cockpit resource management, threat management and error management.

    - Individual psychological characteristics by both flight crew, for the captain reduction of intellectual and behavioural flexibility, fixation on own position and inability to hear prompts from the first officer, for the first officer problems in organisation and sequencing actions) which in the stressful situation with inadequate CRM became apparent.

    - Loss of psychological efficiency the captain (resulting on psychological incapacitation) which led to complete loss of spatial orientation and did not permit to respond properly to correct advice offered by the first officer or the EGPWS PULL UP warning.

    - Absence of criteria to determine psychological incapaciation/loss of health which did not permit the first officer to take more efficient measures.

    - Large arrear of annual leave that could have caused accumulation of fatigue and might have adversely affected the efficiency of the captain.

    - System operations features not described in operations manual.

    - elevator control offset during reconfiguration mode with unreliable airspeed doubles elevator deflection with same control input and has the elevator deflected nose down with the control in neutral position for about 60 seconds which reduced time available to the crew to recognize the situation.

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  18. #78
    Senior Member Evan's Avatar
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    Quote Originally Posted by orangehuggy View Post
    the final report came out, can we discuss?
    Yes. What a sh*tshow. We would do better to discuss why they sometimes don't crash.

  19. #79
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    Quote Originally Posted by orangehuggy View Post
    the final report came out, can we discuss?
    Лучше не надо. С этим упырями только до изжоги додискутируешься.

  20. #80
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    Quote Originally Posted by ATLcrew View Post
    Лучше не надо. С этим упырями только до изжоги додискутируешься.
    ROTFLMFAO!

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