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Pilot Error Pointed Out In Kenya Airways Crash.  
User currently offlineBalkantoDelta From United States of America, joined Apr 2010, 33 posts, RR: 0
Posted (4 years 7 months 4 weeks 1 day 4 hours ago) and read 20380 times:

Goodevening. This does not sound good at all !
Here is the link:
http://news.yahoo.com/s/ap/20100428/...p_on_re_af/af_kenya_cameroon_crash

"Spatial disorientation", pilot didn't notice the 738 banking right, and rolled to right even further causing the spiral nose down. Wow. Doesn't the 738 have some kind of alarm, warning or computer override when you excessively bank to one side ? Shouldn't there be some kind of autopilot correction. Any thoughts on that ?

[Edited 2010-04-28 00:20:03]

44 replies: All unread, showing first 25:
 
User currently offline76er From Netherlands, joined Mar 2007, 573 posts, RR: 1
Reply 1, posted (4 years 7 months 4 weeks 1 day 3 hours ago) and read 20269 times:

The outcome is no surprise. This is at least the 4th accident of this nature involving the 737/320 (Flash, Gulf Air, Armavia) in a relatively short timespan.

Quoting BalkantoDelta (Thread starter):
Doesn't the 738 have some kind of alarm, warning or computer override when you excessively bank to one side ? Shouldn't there be some kind of autopilot correction

There should be an automatic aural 'Banc Angle' call, but the autopilot will not interfere during manual flight.

[Edited 2010-04-28 00:52:50]

User currently offlineXT6Wagon From United States of America, joined Feb 2007, 3432 posts, RR: 4
Reply 2, posted (4 years 7 months 4 weeks 1 day 3 hours ago) and read 20159 times:

Quoting 76er (Reply 1):
There should be an automatic aural 'Banc Angle' call, but the autopilot will not interfere during manual flight.

And its not going to be that useful when you don't have the altitude to fix your screwup. Doesn't take much to lose a couple thousand feet when banked and suddenly you find that wings generate more lift when in air rather than in trees.


User currently offlineflyingAY From Finland, joined Jun 2007, 713 posts, RR: 0
Reply 3, posted (4 years 7 months 4 weeks 1 day 3 hours ago) and read 20045 times:

And the question is, why did it take 3 years to release something like this? I would expect that kind of information is possible to exctract from the CVR and FDR in shorter time. At least in case of other investigations that has been the case.

User currently offlineetherealsky From United States of America, joined Apr 2010, 328 posts, RR: 0
Reply 4, posted (4 years 7 months 4 weeks 1 day 2 hours ago) and read 19838 times:

From article:

Quote:
No instrument scanning was done by the crew during the initial roll, and because it was night, the pilot had no visual references to correct the situation, the report said.
About 90 seconds into the flight, after the pilot notices the rightward drift, he says "we are crashing." Seconds later a young first officer mistakenly tells the pilot to turn right, before correcting himself and saying "left, left, left."

I wonder how much previous flight experience this crew had in actual IMC?! It would seem that in the 21st century, with all the research that's been done on human factors and common causes of accidents like this one, any airline should at least have adequate training to completely eliminate the possibility of such an easily-avoidable accident... I suppose that distractions in the cockpit or maybe some unseen factors could have complicated this situation, but I think it's still fair to say that even newly-minted, instrument-rated private pilots should be familiar with (and able to combat) the problem of spatial disorientation..



"And that's why you always leave a note..."
User currently offlineafriwing From United Kingdom, joined Mar 2008, 62 posts, RR: 0
Reply 5, posted (4 years 7 months 4 weeks 1 day 1 hour ago) and read 19714 times:

Very worrying indeed, specially coming from an airline like KQ. These are grave errors and some basic cockpit procedures have been missed, not something you'd expect from adequately trained and rated crew. Makes me wonder if there're similarities with what happened to ET409 in Beirut. If so, it's time that ICAO, IATA and local CAAs take a second look at pilot training.

From article: "The twin-jet departed Douala for Nairobi in darkness - without seeking or obtaining take-off clearance" .. That in itself is a deeply worrying thing (although not directly contributing to this crash), I thought pilots learned well from previous non-cleared actions.

Quoting flyingAY (Reply 3):
And the question is, why did it take 3 years to release something like this? I would expect that kind of information is possible to exctract from the CVR and FDR in shorter time. At least in case of other investigations that has been the case.

Too much politics involved, I'd say



afriwing
User currently offlinemandala499 From Indonesia, joined Aug 2001, 6965 posts, RR: 76
Reply 6, posted (4 years 7 months 4 weeks 1 day 1 hour ago) and read 19622 times:

Quoting BalkantoDelta (Thread starter):
Doesn't the 738 have some kind of alarm, warning or computer override when you excessively bank to one side ? Shouldn't there be some kind of autopilot correction. Any thoughts on that ?

OK, another CRM breakdown causing an accident.
The report noted that the pilot was 52 but that the first officer was only 23. Before takeoff the pilot admonished his first officer to turn on the plane's windshield wipers, and the report speculated that the first officer, already a shy person, did not speak up to tell the pilot about the flight's problems when he should have because of their relationship.
I've talked to too many people involved in "situations of poor CRM". In those situations, no matter how much whistles and alarms you put... it only takes 1 person to do the wrong thing to quickly descend into disaster...
Add that to get-there-itis... and we have a problem.

Quoting XT6Wagon (Reply 2):
And its not going to be that useful when you don't have the altitude to fix your screwup.

I think the problem in this case is not altitude but attitude.

Anyone has the accident report? I can't seem to link up with CCAA's site where the report is said to be located.

Mandala499



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineSOBHI51 From Saudi Arabia, joined Jun 2003, 3555 posts, RR: 17
Reply 7, posted (4 years 7 months 4 weeks 1 day ago) and read 19535 times:
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Could the same problem be the reason behind Etiopian crash near BEY last December?


I am against any terrorist acts committed under the name of Islam
User currently offlinemandala499 From Indonesia, joined Aug 2001, 6965 posts, RR: 76
Reply 8, posted (4 years 7 months 4 weeks 1 day ago) and read 19450 times:

Quoting SOBHI51 (Reply 7):
Could the same problem be the reason behind Etiopian crash near BEY last December?

Possible, albeit the factors leading into it may be different.

One thing about pilot error that bugs me is that if one would just say pilot error, and goes no further... it doesn't do justice to safety. Anyone has the report?



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineKaiarahi From Canada, joined Jul 2009, 3071 posts, RR: 37
Reply 9, posted (4 years 7 months 4 weeks 23 hours ago) and read 19176 times:

Quoting mandala499 (Reply 8):
Anyone has the report?

I found it here:
http://www.ccaa.aero/images/blogs/d0...fe57c2e008bc8c/rapport%20kenya.pdf
It's a very slow downloading pdf



Empty vessels make the most noise.
User currently offlineRubberJungle From , joined Dec 1969, posts, RR:
Reply 10, posted (4 years 7 months 4 weeks 21 hours ago) and read 18876 times:

This report might be of interest if you're having trouble with the slow download:

http://www.flightglobal.com/articles...manship-led-to-disorientation.html

[Edited 2010-04-28 06:45:14]

User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 11, posted (4 years 7 months 4 weeks 21 hours ago) and read 18704 times:

Quoting etherealsky (Reply 4):
I wonder how much previous flight experience this crew had in actual IMC?! It would seem that in the 21st century, with all the research that's been done on human factors and common causes of accidents like this one, any airline should at least have adequate training to completely eliminate the possibility of such an easily-avoidable accident...

This is just an observation - I have no direct knowledge of the airline's operations or policies - but at age 52, the pilot should have many hundreds, maybe thousands of flights in the dark tropical night with little to no ground reference. A lot of flights in tropical regions are done in hours of darkness, though of course a lot are also visual only daytime landings and takeoffs. Obviously the 23 year old FO has relatively little experience.

Training - yes this is an easily-avoidable accident scenario. But it is also a very easily created accident scenario with near no capability to recover.


User currently offlineMrSkyGuy From United States of America, joined Aug 2008, 1214 posts, RR: 3
Reply 12, posted (4 years 7 months 4 weeks 20 hours ago) and read 18526 times:

Quoting BalkantoDelta (Thread starter):
Wow. Doesn't the 738 have some kind of alarm, warning or computer override when you excessively bank to one side ? Shouldn't there be some kind of autopilot correction. Any thoughts on that ?

It does, and it's quite loud in fact.. it's called the "Bank Angle" alert. The moment the aircraft exceeds 30 degrees of bank in either direction, a rather loud and straightforward male voice alerts "BANK ANGLE, BANK ANGLE". On the Boeing, you can roll her as far as you like until she slides out from loss of lift, but she'll yell at you the entire way warning you to check your instruments before continuing with your current attitude of flight. On the Airbus platforms, FBW prohibits the aircraft from exceeding this "slide out" envelope, but will bank pretty sharply.

Ultimately it's pretty hard for me to believe that a "qualified" (and yes, there's quotes over that for obvious reasons) 737 crew could become spatially disoriented in their aircraft.. the moment a pilot becomes even slightly disoriented, he is taught to repeat this mantra "fly the instruments, fly the instruments, fly the instruments."



"The strength of the turbulence is directly proportional to the temperature of your coffee." -- Gunter's 2nd Law of Air
User currently offlineYXXMIKE From Canada, joined Apr 2008, 310 posts, RR: 0
Reply 13, posted (4 years 7 months 4 weeks 18 hours ago) and read 17632 times:

There should be an automatic aural 'Banc Angle' call,

Quoting MrSkyGuy (Reply 12):
Ultimately it's pretty hard for me to believe that a "qualified" (and yes, there's quotes over that for obvious reasons) 737 crew could become spatially disoriented in their aircraft.. the moment a pilot becomes even slightly disoriented, he is taught to repeat this mantra "fly the instruments, fly the instruments, fly the instruments."

Excuse the ignorance but what do you mean exactly when you say "fly the instruments". Is that a reference to look down and work with what you have in front of you and not what "you think you have outside"?


User currently offlinetdscanuck From Canada, joined Jan 2006, 12709 posts, RR: 80
Reply 14, posted (4 years 7 months 4 weeks 18 hours ago) and read 17560 times:

Quoting BalkantoDelta (Thread starter):
Doesn't the 738 have some kind of alarm, warning or computer override when you excessively bank to one side ?
Quoting YXXMIKE (Reply 13):
There should be an automatic aural 'Banc Angle' call,

Yes, there is a warning and alarm. There is no computer override (the 737 doesn't have FBW flight controls).

Quoting BalkantoDelta (Thread starter):
Shouldn't there be some kind of autopilot correction.

If the autopilot is on, there is. For what are hopefully obvious reasons, the autopilot can't arm itself, so if you're flying manually you don't get that protection.

Quoting YXXMIKE (Reply 13):
Excuse the ignorance but what do you mean exactly when you say "fly the instruments". Is that a reference to look down and work with what you have in front of you and not what "you think you have outside"?

Yes. Fly what the instruments tell you, not what the seat of your pants tells you.

Tom.


User currently onlineMEA-707 From Netherlands, joined Nov 1999, 4358 posts, RR: 35
Reply 15, posted (4 years 7 months 4 weeks 18 hours ago) and read 17477 times:

I have the guts feelings the ET accident at Beirut is also spatial disorientation.
Apart from the other mentioned accidents, Kenya's A-310 in 2000 also crashed after take off in darkness, and some other accidents too. it really seems a cultural thing that crew in Africa and the Mid East seem to rely too much on what they see outside and what they feel is a straight flight instead of their instruments, especially airlines like ET and KQ should have better trained staff.



nobody has ever died from hard work, but why take the risk?
User currently offlineBalkantoDelta From United States of America, joined Apr 2010, 33 posts, RR: 0
Reply 16, posted (4 years 7 months 4 weeks 18 hours ago) and read 17431 times:

Quoting YXXMIKE (Reply 13):
Quoting YXXMIKE (Reply 13):
Excuse the ignorance but what do you mean exactly when you say "fly the instruments". Is that a reference to look down and work with what you have in front of you and not what "you think you have outside"?

Its a term that we flight instructors use to teach our students to do exactly that. The minute you become spatially disoriented you start to want to make all sorts of correction, BUT indeed we teach them LOOK at your instruments, cross check what they indicate and then as hard as it might be do what they are showing you. There comes the terms FLY THE INSTRUMENTS not your inner feeling.

Wow ! A 738 with a pilot of 50 years experience, in a state of the art machine making deadly and rather basic errors like that is a serious problem. The airline will be embarrassed if the Beirut flight comes back with some error like that.


User currently offlineTJCAB From Canada, joined Oct 2004, 335 posts, RR: 0
Reply 17, posted (4 years 7 months 4 weeks 18 hours ago) and read 17123 times:

There should be an automatic aural 'Banc Angle' call,

Quoting MEA-707 (Reply 15):
it really seems a cultural thing that crew in Africa and the Mid East seem to rely too much on what they see outside and what they feel is a straight flight instead of their instruments, especially airlines like ET and KQ should have better trained staff.

I would love to know how you come about this generalized statement! Or, is it the same old biased opinion once again?


User currently onlineMEA-707 From Netherlands, joined Nov 1999, 4358 posts, RR: 35
Reply 18, posted (4 years 7 months 4 weeks 18 hours ago) and read 16948 times:

Quoting TJCAB (Reply 17):
I would love to know how you come about this generalized statement! Or, is it the same old biased opinion once again?

I wish it was different but statistics tell it. Sources like aviation-safety.net have all accidents with circumstances and causes described. Many many major accidents, from the 1968 Windhoek 707 and many Egyptair accidents in the 1960s and 1970s to the Gulf Air 320 in 2000 to Kenya Airways point to spatial disorientation, way more times statistically, while only a single digit percentage of all flights are by African carriers, compared to the USA or Europe. As the airplanes in these accidents usually seem mechanical in order, it must be a training or cultural thing which the aviation world should take very seriously.



nobody has ever died from hard work, but why take the risk?
User currently offlineyellowtail From United States of America, joined Jun 2005, 6350 posts, RR: 2
Reply 19, posted (4 years 7 months 4 weeks 17 hours ago) and read 16664 times:

Quoting TJCAB (Reply 17):
Quoting MEA-707 (Reply 15):
it really seems a cultural thing that crew in Africa and the Mid East seem to rely too much on what they see outside and what they feel is a straight flight instead of their instruments, especially airlines like ET and KQ should have better trained staff.

It is not just Africa buddy....that AA overrun incident in KIN looks to be pilot error (by a first world carrier and first world pilots)...that TA incident in TGU...looks like Pilot error.....AF in YZZ.....etc etc.....there is even speculation that pilot skills was part of the problem that led to te eventual crash of AF447



When in doubt, hold on to your altitude. No-one has ever collided with the sky.
User currently offlineMrSkyGuy From United States of America, joined Aug 2008, 1214 posts, RR: 3
Reply 20, posted (4 years 7 months 4 weeks 17 hours ago) and read 16404 times:

Quoting yellowtail (Reply 19):
It is not just Africa buddy....that AA overrun incident in KIN looks to be pilot error (by a first world carrier and first world pilots)...that TA incident in TGU...looks like Pilot error.....AF in YZZ.....etc etc.....there is even speculation that pilot skills was part of the problem that led to te eventual crash of AF447

True, nobody's going to argue with you there.. but I also don't think anyone is going to disagree with me that they didn't come to this thread without preconceptions of incompetence due to the location of the carrier and incident.



"The strength of the turbulence is directly proportional to the temperature of your coffee." -- Gunter's 2nd Law of Air
User currently offlineflybaurLAX From United States of America, joined Oct 2008, 638 posts, RR: 0
Reply 21, posted (4 years 7 months 4 weeks 17 hours ago) and read 16359 times:

Quoting MrSkyGuy (Reply 12):
On the Boeing, you can roll her as far as you like until she slides out from loss of lift, but she'll yell at you the entire way warning you to check your instruments before continuing with your current attitude of flight.

The 737NG only gives the double alert once, unless you go under 30 degrees and then cross it again.

Quoting BalkantoDelta (Thread starter):
Doesn't the 738 have some kind of alarm, warning or computer override when you excessively bank to one side ?

The 737 doesn't, but the 777 and 787 roll the aircraft back to wings level if you do exceed that, but you can actually override that with muscle power and keep the bank going.



Boilerup! Go Purdue!
User currently offlineSolarFlyer22 From US Minor Outlying Islands, joined Nov 2009, 1125 posts, RR: 0
Reply 22, posted (4 years 7 months 4 weeks 17 hours ago) and read 16061 times:

Quoting MEA-707 (Reply 18):
it must be a training or cultural thing which the aviation world should take very seriously.

There are some definite cultural issues especially in the middle east. I don't know if that contributed to this particular accident but I can tell you from past personal experience its much more difficult to challenge someone old and more experienced. There is also a kind of a blaise attitude toward things not realizing the impact small decisions can have.


User currently offlineAirFrance744 From United States of America, joined Aug 2009, 81 posts, RR: 0
Reply 23, posted (4 years 7 months 4 weeks 16 hours ago) and read 15369 times:

This sounds very similar in almost all aspects to Flash Airlines flight 604. Spacial disorientation really is something that needs to be checked in pilots more often, IMO.

http://en.wikipedia.org/wiki/Flash_Airlines_Flight_604

The Air Crash Investigation show on it.
http://www.youtube.com/watch?v=O6uLG...laynext_from=PL&index=0&playnext=1

[Edited 2010-04-28 12:04:08]


Flown over 115,000 miles and I'm only 19!
User currently offlinespudsmac From United States of America, joined Feb 2008, 309 posts, RR: 0
Reply 24, posted (4 years 7 months 4 weeks 14 hours ago) and read 13146 times:

Failboat

Basic instrument flying = FAIL


25 mandala499 : Basic IFR flight 101... it's amazing how many times one fails on that albeit momentarily in 99.999999999999999% of the time... and then, in the rare
26 Amexair : I like this statement. I think the old timers do not like to rely on technology or computers too much, perhaps the main reason why they are very vuln
27 413X3 : That generational comment is not based on fact. The older generation is more used to relying on instruments. Where do people come up with this stuff
28 mandala499 : It's not about trusting or not trusting your instruments... I agree with: The problem is when you have lack of systems understanding combined with an
29 Asu : I think the issue of culture comes in especially when looking at CRM issues such as presented here. It is well documented in Organizational Behaviour
30 413X3 : There are also a large group of younger pilots who lack actual flying skills and instead rely on these systems to do everything for them. It goes bot
31 faro : Makes one wonder whether present simulator training adequately caters to spacial disorientation situations. Maybe a funky super-duper simulator with:
32 airbuske : What makes me particularly sad is that as of last year, this "bullying" in the cockpit still seems to be happening with KQ. In August/September 2009,
33 Navigator : Unfortunately spatial disorientation is very much increasing in airline operations and a cause of concern since a growing number of accidents in rece
34 413X3 : The pilot was not flying the instruments, he continued to bank right without realizing the airplane was banking right.
35 Post contains links faro : Sounds a bit like the Air India 855 in 1978 except that that flight was at much lower altitude and the crew did not fly to the backup instruments aft
36 Amexair : Indeed i was quite vague but what i meant was that the older generation would prefer traditional mechanical gauges instead of the glass cockpits whic
37 Pihero : Yes, you're right. The reason is that we have nowadays a generation of high-performance airplanes with very efficient flighht controls, high thrust-t
38 yellowtail : Sully!!!!!!!!!!!!!!!
39 Post contains images PRAirbus : Many times pilots like to play "God" or super-hero...too confident avoiding common sense and coordinated procedures. Nature is also unforgiving...avia
40 ETinCaribe : From the CVR transcript within the report, I could not see any actual bullying (see 4:38.6 on pg 11 and then at 7:29 onwards) only one correction by
41 BalkantoDelta : Forgive me if I sound ignorant at this point, but I am so glad i tend to fly US carriers. Not that it means anything concrete in terms of safety, but
42 MrSkyGuy : You think MEX airspace is bad? Try Brazil.
43 alwaysontherun : "Bad ass", over flying your destination by 20 minutes until the air hostess warns that you have now long time passed your original ETA! "Bad ass", th
44 bestwestern : The KE 74F crash at STN was also spatial orientation related.
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