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Ntsb Says Pilot Error Caused CO Crash At DEN  
User currently offlineUAL747DEN From United States of America, joined Dec 2003, 2392 posts, RR: 11
Posted (4 years 2 months 2 weeks 6 days 7 hours ago) and read 17764 times:

Just like the title says the NTSB is reporting that pilot error caused the CO 737 to crash off of the runway at DEN in 2008.

Here is a link to the story
http://www.9news.com/news/article.aspx?storyid=143487&catid=339

Does anyone know what action CO took against this pilot if any?


/// UNITED AIRLINES
30 replies: All unread, showing first 25:
 
User currently offlinePlaneAdmirer From United States of America, joined Jul 2009, 564 posts, RR: 0
Reply 1, posted (4 years 2 months 2 weeks 6 days 7 hours ago) and read 17679 times:

It doesn't quite come to that conclusion, from the article:

The air traffic controller who cleared the plane for takeoff told pilots there was a crosswind of 31 mph, which was the reading on one of two wind sensors nearest the runway. However, the controller didn't mention that the other wind sensor was recording gusts of as much as 46 mph.

"Had the crew known of the actual current wind conditions as displayed on sensor No. 2, which exceeded Continental's ... guideline, they would have waited until wind conditions improved or requested a different runway," the airline said.

I have another question considering the number of runways at DEN - why wasn't the flight directed to a runway where it could have taken off into the wind?


User currently offlineAirportugal310 From Tokelau, joined Apr 2004, 3643 posts, RR: 2
Reply 2, posted (4 years 2 months 2 weeks 6 days 7 hours ago) and read 17584 times:

The blame game is apparent in the article...FAA blames airline, airline blames controllers, controllers (their union) blame airport...

Could the airport blame the FAA and bring it full circle?!



I sell airplanes and airplane accessories
User currently offlineUAL747DEN From United States of America, joined Dec 2003, 2392 posts, RR: 11
Reply 3, posted (4 years 2 months 2 weeks 6 days 6 hours ago) and read 17200 times:

Quoting PlaneAdmirer (Reply 1):
It doesn't quite come to that conclusion, from the article:

The article has changed, that is not the original article that I linked to. The story I read was much longer and had a lot more detail. It said that the NTSB had ruled the cause of the accident to be pilot error. The article said that the pilot tried to use the tiller to direct the plane back onto the runway but the nose had left the ground so their was no response. The NTSB had found that the pilot should have used the rudder and if he would have used the rudder the aircraft should have been able to deal with the crosswind and successfully takeoff.

I don't know where that story went but that is what I read. I will try to locate it or maybe something on another site. If that is what the NTSB is really reporting then their should be multiple sources on it. I cannot understand why the story changed and they don't have any sort of link to the original story, to me this is sloppy journalism.



/// UNITED AIRLINES
User currently offlineKPHXFlyer From United States of America, joined Mar 2008, 413 posts, RR: 1
Reply 4, posted (4 years 2 months 2 weeks 6 days 6 hours ago) and read 17157 times:

Quoting UAL747DEN (Reply 3):
The article said that the pilot tried to use the tiller to direct the plane back onto the runway but the nose had left the ground so their was no response. The NTSB had found that the pilot should have used the rudder and if he would have used the rudder the aircraft should have been able to deal with the crosswind and successfully takeoff.

I, too, read the same article you did.

I'm wondering why if the previous two times that he used the rudder, did he elect to use the tiller at near take-off speed? Don't most commerical planes disable the nosewheel turning above a certain airspeed or loading?

[Edited 2010-07-13 10:35:57]

User currently offlineC767P From United States of America, joined Oct 2008, 886 posts, RR: 2
Reply 5, posted (4 years 2 months 2 weeks 6 days 6 hours ago) and read 17077 times:

I don’t believe the probable cause from the NTSB is available yet. At least it is not on their site.

User currently offlineXFSUgimpLB41X From United States of America, joined Aug 2000, 4204 posts, RR: 37
Reply 6, posted (4 years 2 months 2 weeks 6 days 5 hours ago) and read 16803 times:

Simplifying things to "pilot error" is absolutely stupid.

There is never just one thing that causes any accident. In fact, "probable cause" should be changed to "probable largest contributor."



Chicks dig winglets.
User currently offlinespacecadet From United States of America, joined Sep 2001, 3629 posts, RR: 12
Reply 7, posted (4 years 2 months 2 weeks 6 days 5 hours ago) and read 16738 times:

Quoting XFSUgimpLB41X (Reply 6):
There is never just one thing that causes any accident. In fact, "probable cause" should be changed to "probable largest contributor."

There is always one final link in the chain that, if it hadn't occurred, the accident would not have occurred either. I think you're misunderstanding cause and effect. Yes, all accidents are the result of a chain of events. However, if a pilot doesn't do what he's supposed to do, and that's the final link in the chain that causes the accident, then that is the direct cause of the accident.

It's just like if you're speeding in your car in the rain and you hit somebody from behind because you can't stop in time. Yes, the rain was a factor in that accident, as was the speed and the strength and design of the brakes. But the real cause was your decision to drive too fast in dangerous conditions. Without that, there would have been no accident.

If an accident could have been avoided by a pilot following proper procedures when he didn't, then it is pilot error.

[Edited 2010-07-13 11:39:40]


I'm tired of being a wanna-be league bowler. I wanna be a league bowler!
User currently offlineSlider From United States of America, joined Feb 2004, 6818 posts, RR: 34
Reply 8, posted (4 years 2 months 2 weeks 6 days 4 hours ago) and read 16662 times:

I'm curious why the accodent report isn't out yet...

This happened Dec 2008; this is an extraordinarily long time.


User currently offlineikramerica From United States of America, joined May 2005, 21534 posts, RR: 59
Reply 9, posted (4 years 2 months 2 weeks 6 days 4 hours ago) and read 16566 times:

The headline should read: "NTSB Says Pilot Error Contributed to CO Crash at DEN" and anything else is poor journalism.

Quoting spacecadet (Reply 7):
There is always one final link in the chain that, if it hadn't occurred, the accident would not have occurred either.

That's just not true.

If the tower had told the pilot the cross wind was over 40, this accident would not have happened, because the pilot would have waited to take off or requested a different departure runway.

So just because that was a fait accompli doesn't mean that it no longer a cause of the crash.

Now trying to steer out of a spin at near takeoff speed is stupid, but had all the information been presented to the pilot, he'd not have been in that situation to begin with.



Of all the things to worry about... the Wookie has no pants.
User currently offlineULMFlyer From Brazil, joined exactly 8 years ago today! , 475 posts, RR: 1
Reply 10, posted (4 years 2 months 2 weeks 6 days 3 hours ago) and read 14681 times:

Still waiting for the final report, but from this early NTSB Factual Report, it was already clear that there was very little to no rudder pedal input, even with the nose pointing 30 degrees to the left of the RWY heading.

In defense of the PF, ABC news reports that

Quote:
Also working against the captain was Continental's flight simulator training for pilots. It included training for steady high crosswinds, but not for gusts, investigators said. Due to a quirk in the simulator's software, the airline thought pilots were being exposed to gusts, but didn't learn that wasn't the case until the NTSB's investigation, investigators said. They said that is probably the case at other airlines.

The board recommended that the Federal Aviation Administration require airlines to incorporate realistic, gusty winds into their pilot training.



Let's go Pens!
User currently offlinekaitak From Ireland, joined Aug 1999, 12480 posts, RR: 34
Reply 11, posted (4 years 2 months 2 weeks 6 days 2 hours ago) and read 14294 times:

Quoting ULMFlyer (Reply 10):
Also working against the captain was Continental's flight simulator training for pilots. It included training for steady high crosswinds, but not for gusts, investigators said. Due to a quirk in the simulator's software, the airline thought pilots were being exposed to gusts, but didn't learn that wasn't the case until the NTSB's investigation, investigators said. They said that is probably the case at other airlines.

The board recommended that the Federal Aviation Administration require airlines to incorporate realistic, gusty winds into their pilot training.

This will presumably make it very difficult for the airline to fire the crew? (Presumably they would have been grounded since the accident?)


User currently offlineULMFlyer From Brazil, joined exactly 8 years ago today! , 475 posts, RR: 1
Reply 12, posted (4 years 2 months 2 weeks 6 days ago) and read 12580 times:

The accident synopsis, including the executive summary, conclusion, probable cause and recommendation, as well as link to the full docket, is here: http://www.ntsb.gov/Publictn/2010/aar1004.htm

Quoting PlaneAdmirer (Reply 1):
I have another question considering the number of runways at DEN - why wasn't the flight directed to a runway where it could have taken off into the wind?

Item 18 under conclusions answers your question:

Quote:
18. Currently, the Denver International Airport air traffic control tower runway selection policy does not clearly account for crosswind components when selecting a runway configuration.

Go figure...



Let's go Pens!
User currently offlinem11stephen From United States of America, joined Aug 2008, 1247 posts, RR: 1
Reply 13, posted (4 years 2 months 2 weeks 6 days ago) and read 12149 times:

Quote:
No one was killed, but six people were seriously injured and dozens more were treated for minor injuries. Board members praised flight attendants for getting everyone off the plane before the fire entered the passenger cabin.

Kudos to the cabin crew for getting everyone off the plane fast!  



My opinions, statements, etc. are my own and do not have any association with those of any employer.
User currently offlineFlighty From United States of America, joined Apr 2007, 8565 posts, RR: 2
Reply 14, posted (4 years 2 months 2 weeks 5 days 23 hours ago) and read 11414 times:

Quoting spacecadet (Reply 7):
However, if a pilot doesn't do what he's supposed to do, and that's the final link in the chain that causes the accident, then that is the direct cause of the accident.

Unfortunately the NTSB is not always so logical.

The Air Midwest B1900 crash at CLT was blamed on total mechanical negligence, BUT with a contribution from overloading.

By this logic, gravity is also to blame. Nobody would have died if gravity didn't cause the crash. Each crash should have a primary cause, but the NTSB sometimes waters it down.


User currently offlinerailker From Canada, joined Aug 2006, 171 posts, RR: 0
Reply 15, posted (4 years 2 months 2 weeks 5 days 22 hours ago) and read 11334 times:

Quoting UAL747DEN (Reply 3):
The article said that the pilot tried to use the tiller to direct the plane back onto the runway but the nose had left the ground so their was no response.

I would have thought the tiller would be strictly for ground handling, speeds below 60 knots kind of thing, not V1 speeds ...


User currently offlineUAL747DEN From United States of America, joined Dec 2003, 2392 posts, RR: 11
Reply 16, posted (4 years 2 months 2 weeks 5 days 22 hours ago) and read 10813 times:

Quoting railker (Reply 15):
I would have thought the tiller would be strictly for ground handling, speeds below 60 knots kind of thing, not V1 speeds ...

Yeah I tend to agree with you! I have never piloted anything like a 737 (more like a C172!) before so I don't know exactly how things work up in the cockpit but from a completely uneducated point of view I would think at those kinds of speeds the last thing you would want to do is turn the gear. If what I read is correct and the nose was already off of the ground there was no possibility at all for the tiller to do anything.

Can a pilot who flies the 737 comment about the first couple of seconds after the nose lifts off of the ground, it seems obvious to me that you would be able to notice that your gear has lifted but is it as obvious as it seems? The largest aircraft I have ever been in the cockpit for takeoff in is a large business jet (like a 7X) and it was very clear when that gear left the ground. The sound changed, the vibrations changed, it just seemed obvious. So what do you think 737 pilots?



/// UNITED AIRLINES
User currently offline7673mech From United States of America, joined Mar 2004, 730 posts, RR: 0
Reply 17, posted (4 years 2 months 2 weeks 5 days 21 hours ago) and read 10463 times:
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Quoting XFSUgimpLB41X (Reply 6):
Simplifying things to "pilot error" is absolutely stupid.

  

Not sure if the poster was reading the same article.
No ever said it was pilot error.


User currently offlineAesma From France, joined Nov 2009, 6688 posts, RR: 12
Reply 18, posted (4 years 2 months 2 weeks 5 days 21 hours ago) and read 10408 times:

Quoting spacecadet (Reply 7):
It's just like if you're speeding in your car in the rain and you hit somebody from behind because you can't stop in time. Yes, the rain was a factor in that accident, as was the speed and the strength and design of the brakes. But the real cause was your decision to drive too fast in dangerous conditions. Without that, there would have been no accident.

Well, they decided to take off in dangerous conditions, NOT KNOWING THEY WERE DANGEROUS. So your example is unfair.



New Technology is the name we give to stuff that doesn't work yet. Douglas Adams
User currently offline413X3 From United States of America, joined Jul 2008, 1983 posts, RR: 0
Reply 19, posted (4 years 2 months 2 weeks 5 days 20 hours ago) and read 9668 times:

the tiller is essentially ineffective above a certain speed. But when people start talking about how their view is uneducated they probably shouldn't be handing out blame...

User currently offlinePlaneAdmirer From United States of America, joined Jul 2009, 564 posts, RR: 0
Reply 20, posted (4 years 2 months 2 weeks 5 days 20 hours ago) and read 9544 times:

So if ATC didn't tell them about the gusts and for some reason didn't direct aircraft to take into the wind, at one point is the Government actually responsible? It's pretty hard to be in charge and not take/accept responsibility. Yes, I get the part about the the simulators not testing for gusts which surprises me beyond words.

User currently offlineseven3seven From United States of America, joined Apr 2005, 318 posts, RR: 23
Reply 21, posted (4 years 2 months 2 weeks 5 days 19 hours ago) and read 9137 times:

This captain made a mistake. The tiller isnt used at high speeds. And Im guessing he's never really had to use the rudder much or its just been too long.

Luckily there were no fatalities. And it is human nature to want to assign blame, especially in America. But does he deserve to be fired? I dont think so.

In aviation it isnt productive to blame mistakes after the fact. Its more productive to learn from mistakes and train for them. If pilots were afraid every single mistake would cost them their job it would create a bad atmosphere in flight operations which could lead to a self fulfilling spiral into less than safe flights.

The captain will be retrained. CO and other airlines will learn from this mistake and include more of it in training. The airline industry will be safer for it.



My views are mine alone and are not that of any of my fellow employees, officers, or directors at my company
User currently offlineokie From United States of America, joined Jul 2003, 3061 posts, RR: 3
Reply 22, posted (4 years 2 months 2 weeks 5 days 19 hours ago) and read 8857 times:

Quoting PlaneAdmirer (Reply 1):
The air traffic controller who cleared the plane for takeoff told pilots there was a crosswind of 31 mph, which was the reading on one of two wind sensors nearest the runway. However, the controller didn't mention that the other wind sensor was recording gusts of as much as 46 mph



Irregardless that CO had a 33 knot limit on cross wind component and there were higher gusts, the information they received was 27 knot cross wind.
Okie is just not buying that you can not expect to have to have some rudder input on a 735 on take-off with a 27 knot cross wind gusting or not. There were no rudder inputs on the take off roll.

Okie


User currently offlineATCtower From United States of America, joined Dec 2007, 542 posts, RR: 3
Reply 23, posted (4 years 2 months 2 weeks 5 days 18 hours ago) and read 8638 times:

Quoting XFSUgimpLB41X (Reply 6):
Simplifying things to "pilot error" is absolutely stupid.

There is never just one thing that causes any accident. In fact, "probable cause" should be changed to "probable largest contributor."

What is unfortunate is there is usually one course of action which 'if averted' would drastically affect the series of actions. In this instance, though I will disagree at times with the NTSB, it was in fact an error of the pilot to a great extent.

Quoting ikramerica (Reply 9):

If the tower had told the pilot the cross wind was over 40, this accident would not have happened, because the pilot would have waited to take off or requested a different departure runway.

And in a perfect world pilots would never break weather minima. In reality, I have warned pilots of the excessive x-wind component who have wholeheartedly disregarded the warning in the interest of destination arrival windows. Suggesting an aircraft would unquestionably hold is absurd.

Quoting kaitak (Reply 11):
This will presumably make it very difficult for the airline to fire the crew? (Presumably they would have been grounded since the accident?)

The crew is till fully employed and active with CO as of my last inquriy.



By reading the above post you waive all rights to be offended. If you do not like what you read, forget it.
User currently offlineantoniemey From United States of America, joined Dec 2005, 1572 posts, RR: 4
Reply 24, posted (4 years 2 months 2 weeks 5 days 18 hours ago) and read 8413 times:

Quoting kaitak (Reply 11):
This will presumably make it very difficult for the airline to fire the crew? (Presumably they would have been grounded since the accident?)

Why would they be fired? Or grounded for longer than it takes to interview and do remedial training? Sure, it was an accident with a hull loss and injuries, but trucking companies don't automatically fire a trucker who skids off the road in a rainstorm.

People make mistakes. And since this was, fairly clearly, an accident and not negligence on the part of the pilot(s) there's no grounds for termination.

Quoting seven3seven (Reply 21):
Luckily there were no fatalities. And it is human nature to want to assign blame, especially in America. But does he deserve to be fired? I dont think so.

   The French legal system has us beat all hollow for wanting to assign blame, though...


Quoting okie (Reply 22):
There were no rudder inputs on the take off roll.

According the the article that's at the link (now at least) the rudder was used twice in the first 12 seconds and had just been released 4 seconds prior to the gust that pushed the aircraft off the runway.

Quote:
The captain had twice applied the plane's right rudder during the first 12 seconds of the takeoff roll to correct its direction back to the right.
Quoting ATCtower (Reply 23):
The crew is till fully employed and active with CO as of my last inquriy.

Good to hear.



Make something Idiot-proof, and the Universe will make a more inept idiot.
25 dldtw1962 : No matter what the out come of this report. The bottom line the pilot is always going to be blamed for a crash. After all he/she is responsible for th
26 burnsie28 : You do realize that every crash in the end is pilot error, the NTSB always says this and it ends up to pilot error, such as this system gave wrong im
27 CALTECH : Can not remember the exact numbers , but IIRC, rudder pedals only give some 12 degrees of nose gear steering. Rudder pedals also give rudder input, bu
28 ikramerica : The headline to the linked story sure did. Has it changed? Well, it's CO's policy for the 737. And anyway, what are you trying to say? That because s
29 crownvic : Good question...how come no answer????
30 PGNCS : Not. Again, not. The truth is that most accidents do have a human error identified, but many AARs do not have pilot error findings in either the conc
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