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ET409 Accident Investigation Quietly Published  
User currently offlinePihero From France, joined Jan 2005, 4591 posts, RR: 77
Posted (2 years 7 months 18 hours ago) and read 13996 times:
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Here is the official document, which I hadn't have time to thoroughly read and study :Final Investigation Report on ET 409 Accident off the Coast of Beirut
I stumbled upon it after reading an article on Aero Safety World, dated March 2012,
Spiral Dive

These two texts make some sobering thoughjts.


Contrail designer
17 replies: All unread, jump to last
 
User currently offlinelhr380 From , joined Dec 1969, posts, RR:
Reply 1, posted (2 years 7 months 17 hours ago) and read 13718 times:

Briefly read thru the main parts. Scary reading...........

User currently offlineKC135TopBoom From United States of America, joined Jan 2005, 12158 posts, RR: 51
Reply 2, posted (2 years 7 months 17 hours ago) and read 13627 times:

From reading it, the crew found themselves in a sever thunderstorm, and became confused about what was actually happening to their aircraft. It also appears they never completed the after take-off and climb checklist.

User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 3, posted (2 years 7 months 16 hours ago) and read 13382 times:

Quoting KC135TopBoom (Reply 2):
From reading it, the crew found themselves in a sever thunderstorm, and became confused about what was actually happening to their aircraft.

I don't see anything in the report stating that they actually found themselves in a severe thunderstorm. Sure, there were isolated cells to the SW, NW and NE which increased their workload and stress levels, but these CBs were beyond 10km from the airport.

My reading is that it all starts with a mistrimmed take off, followed by IFR flight so FUBAR that I can only wait for what PIhero has to say before trying to shape my own opinion any further.



Let's go Pens!
User currently offlineHBGDS From , joined Dec 1969, posts, RR:
Reply 4, posted (2 years 7 months 12 hours ago) and read 12456 times:

Quoting ULMFlyer (Reply 3):
I don't see anything in the report stating that they actually found themselves in a severe thunderstorm. Sure, there were isolated cells to the SW, NW and NE which increased their workload and stress levels, but these CBs were beyond 10km from the airport.

On the contrary, the CVR records rain noise (report pp. 23-24), and crew of other flights confirm rain in the vicinity of the airport, even though outer realms are clear. (p. 56)


User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 5, posted (2 years 7 months 12 hours ago) and read 12263 times:

Quoting HBGDS (Reply 4):
On the contrary, the CVR records rain noise (report pp. 23-24), and crew of other flights confirm rain in the vicinity of the airport, even though outer realms are clear. (p. 56)

I was not disputing that the weather was bad and there was rain. I was disputing the fact that they flew into a *severe* thunderstorm and that this was a contributing factor in their loss of situational awareness. From the report:

Quote:
METAR and TAFOR reports indicate significant meteorological conditions were in the area South West, North West and North East of the airport with isolated CB and thunderstorm activities beyond 10 km from the airport.The D-ATIS was transmitting the METAR. Reports from arriving traffic at the time of the accident confirmed the reported meteorological conditions.
Quote:
11- The weather on the night of the accident was a contributor in increasing the workload on both the controllers and the Flight Crew.

12- The aircraft did fly in heavy rain and icing conditions, but it did not encounter any severe turbulence or lightning strike.



Let's go Pens!
User currently offlineRubberJungle From , joined Dec 1969, posts, RR:
Reply 6, posted (2 years 7 months 3 hours ago) and read 8411 times:

There was nothing "quiet" about the publication.

The report was released back in mid-January, and Ethiopian Airlines kicked up a very public storm, insisting that the Lebanese had reached the wrong conclusion.

http://www.flightglobal.com/news/art...hiopian-airlines-737-crash-367118/

http://www.flightglobal.com/blogs/fl...2012/01/sticking-to-the-facts.html

Very few people on either side have been quiet, notably those who ought to have been.



[Edited 2012-03-25 06:01:14]

User currently offlineltbewr From United States of America, joined Jan 2004, 13138 posts, RR: 15
Reply 7, posted (2 years 7 months 2 hours ago) and read 7933 times:

As to the lack of publicity of the final report, let us not forget that for months there has been continuing social and political issues in Lebanon and more importantly in adjacent Syria and Israel and with it happening 2 years ago, it just will get buried in the news but for maybe in Ethiopia.

Still, what the investigations suggest is that as with many air crashes, a series of events and a number of factors contributed to this one. ET is also incised as this crash makes their crew look incompetent and for an airline long considered one of the best run African based airlines, pride is as stake as well as economic affects to it from such a crash scenario.


User currently offlineKC135TopBoom From United States of America, joined Jan 2005, 12158 posts, RR: 51
Reply 8, posted (2 years 7 months 1 hour ago) and read 7636 times:

Quoting ULMFlyer (Reply 5):
Quoting HBGDS (Reply 4):On the contrary, the CVR records rain noise (report pp. 23-24), and crew of other flights confirm rain in the vicinity of the airport, even though outer realms are clear. (p. 56)

I was not disputing that the weather was bad and there was rain. I was disputing the fact that they flew into a *severe* thunderstorm and that this was a contributing factor in their loss of situational awareness. From the report:
Quoting ULMFlyer (Reply 5):
Quote:11- The weather on the night of the accident was a contributor in increasing the workload on both the controllers and the Flight Crew.

12- The aircraft did fly in heavy rain and icing conditions, but it did not encounter any severe turbulence or lightning strike.

There would be only to reasons for the near extreme manuvers that airplane went through after take-off and prior to the crash. 1.) Pilot inputs into the controls. 2.) Weather factors.

Just because there was no recorded turbulance or lightening strikes does not mean the aircraft was not flying through sever weather. The wind gust factors very well could explain the bank angles to about 68 degrees, as well as the pitch angles of as much as +30 degrees to -23 degrees. The airplane stalled twice during its brief last flight. Yes, the airplane was mis-trimmed for the take-off trim setting, and the crew continued to mis-trim it during the flight, trimming as 9+ units of nose up trim.

As far as Ethiopa disagreeing with the final accident report, and claiming the wreckage was not recovered, there is nothing that prevents the Ethiopian Government or ET from recovering the wreckage, it is still there as far as I know, and conducting their own accident investigation. This airplane was brought down by the storm, but the actions, or lack of action, by the crew also contributed to the accident. In the end, this comes out to be pilot error as they had many chances to get out of the bad weather. They didn't do that, nor could they ever get onto the assigned heading from ATC of 270 degrees, dispite acknowledging the ATC order many times. Nor did the crew tell ATC why they could not seem to stabilize the airplane and its heading.


User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 9, posted (2 years 7 months 1 hour ago) and read 7444 times:

Quoting KC135TopBoom (Reply 8):
Just because there was no recorded turbulance or lightening strikes does not mean the aircraft was not flying through sever weather. The wind gust factors very well could explain the bank angles to about 68 degrees, as well as the pitch angles of as much as +30 degrees to -23 degrees. The airplane stalled twice during its brief last flight. Yes, the airplane was mis-trimmed for the take-off trim setting, and the crew continued to mis-trim it during the flight, trimming as 9+ units of nose up trim.

Not according to the report. From p. 59:

Quote:
According to the DFDR data and the analysis of this data reproduced during the simulation performed at the Boeing facilities in September 2010 (refer to section 1.16.3 and Appendix K), the flight profile was not significantly affected by winds. The flight profile was the direct result of the flight controls inputs and of thrust settings; the simulation proved that the aircraft was recoverable at every stage of the flight till the last few seconds when passing 3,000‟ with a very high rate of descent and increasing speed beyond the maximum certified. Simulation beyond that point would not allow a realistic reproduction of the aircraft behavior under these excessive prevailing conditions.



Let's go Pens!
User currently offlineraffik From United Kingdom, joined Feb 2006, 1716 posts, RR: 4
Reply 10, posted (2 years 6 months 4 weeks 1 day 21 hours ago) and read 5136 times:

I think people who are blaming the weather conditions for this crash need to think again.
The weather conditions were WELL within a safe envelope for operations and indeed aircraft just before
and after took off and landed with no problems.

Aircraft are designed to operate safely in areas of turbulence and inclement weather conditions - as long
as the crew are correctly trained and are in full control of the aircraft. This was down to pilot error - they
were not in control of the aircraft and that is what caused the accident. The weather conditions were a
contributory factor but again, a competent crew would have departed, quickly established the correct
heading and climbed normally.

Shame on Ethiopian for not stepping up to the report, accepting the hard fact and instead of ensuring flight
crew were properly qualified with night time departures they continuously blame the Lebanese government
for not conducting the report properly (which they did). They are trying to save face, but out of decency they
should accept that on this occasion their crew did not handle that departure correctly.



Happy -go- lucky kinda guy!
User currently offlinePihero From France, joined Jan 2005, 4591 posts, RR: 77
Reply 11, posted (2 years 6 months 4 weeks 1 day 19 hours ago) and read 3781 times:
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I cannot understand the company's stance on this accident as they did themselves a lot of harm by not agreeing to the findings of the IC:
- The conclusions were more on subtle incapacitation of the captain than any mistake / error made.
- What happens now inside ET training department is open to questions.

What puzzles me is the very discrete mention of a possible vertigo for the captain (and probably the FO in their last moments) as I have claimed since we began investigating on this accident, the succession of vastly differing accelerations would be conductive to spatial disorientation. See on this subject the Sotchi and the Bahrain accidents.
My final remark on that crew is about missing airmanship basics, like keeping one's airplane in-trim, performing in time the various checklists...etc...
The weather : I really do not think they saw anything out of the ordinary, the plateaux of Ethiopia being the cradle of some monstruous babies in season, and flying all over Africa is basically being in-and-out of the ITCZ, which could give some fun flying experience if one is into thrills... there is enough fun for everybody here !

Quoting RubberJungle (Reply 6):
There was nothing "quiet" about the publication.

I've just found out that imiakhtar opened a thread on the publication date (17/01/2012) but wasn't followed. Sorry

THere is, IMO, a final aspect of the accident that is quite sad : ATC saw the whole thing and I have a feeling they could see a tragic ending to the wild trajectory on the 738. Maybe they could have been more assertive in their clearances instead of trying to explain the whys and reasons for turning left to a westerly heading.
Your opinions ?



Contrail designer
User currently offlineltbewr From United States of America, joined Jan 2004, 13138 posts, RR: 15
Reply 12, posted (2 years 6 months 4 weeks 1 day 19 hours ago) and read 3459 times:

I hope I am not just stirring the pot, but did this aircraft have to fly in certain patterns departing from this airport due to the political situation in the region? Was there pressure, including political, technical and economic, to get this flight out by a certain time so couldn't delay it's takeoff despite the unsettled weather?

User currently offlineraffik From United Kingdom, joined Feb 2006, 1716 posts, RR: 4
Reply 13, posted (2 years 6 months 4 weeks 1 day 18 hours ago) and read 3006 times:

Quoting ltbewr (Reply 13):

I hope I am not just stirring the pot, but did this aircraft have to fly in certain patterns departing from this airport due to the political situation in the region? Was there pressure, including political,

No pressure for this flight to operate any differently to the many other flights in and out of Beirut.
Ethiopian have been serving Beirut for many years without incident, political or otherwise.
That aircraft made a very unusual route because they did not follow the orders of air traffic control.



Happy -go- lucky kinda guy!
User currently offlinePihero From France, joined Jan 2005, 4591 posts, RR: 77
Reply 14, posted (2 years 6 months 4 weeks 1 day 18 hours ago) and read 2712 times:
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Quoting ltbewr (Reply 13):
did this aircraft have to fly in certain patterns departing from this airport due to the political situation in the region?

I have to answer yes : The flight has to avoid Israeli airspace and has to follow some drastic altitude limitations in order to respect the LATEB 1Delta trajectory : above 13,000 ft over CAK (Cheka VOR) and FL 290 at Lateb, some 35 Nm away. On many aircraft, the only way to achieve that sort of performance is at best angle, or to make an orbit or two. The crew has to be well aware of that departure characteristic, especially at high TOWs. On this particular flight, I'd surmise that they planned to remain well under 250 kts.

[Edited 2012-03-25 15:08:53]


Contrail designer
User currently offlineAlias1024 From United States of America, joined Oct 2004, 2777 posts, RR: 2
Reply 15, posted (2 years 6 months 4 weeks 22 hours ago) and read 2143 times:

The human factors section was well done. The comments about subtle incapacitation and chronic fatigue were well thought out. I hope airline safety departments worldwide are paying attention.


It is a mistake to think you can solve any major problems with just potatoes.
User currently offlineAmexair From Ethiopia, joined Sep 2009, 61 posts, RR: 4
Reply 16, posted (2 years 6 months 4 weeks 18 hours ago) and read 1914 times:

The report is very contradicting and quite confusing too. What puzzles me is that before the final spin towards the ground, the pilots almost lost control of the aircraft two times. Does this not somehow put a question in the head of the pilot in command to really go over his instruments and see what is really happening. If it was indeed spatial disorientation, they would have probably lost full control the first time it rolled to the right. This shows that they were indeed monitoring the HDI which also gives information about whether or not the AP is disconnected or not. The other thing, which no one bothered to mention is

Quote:
Eye witness reports including a Tower controller reported seeing “a light”, “an orange explosion”, “a ball that lasted 2-3 seconds

, or a “ball of fire” around the time of the accident." Does this not raise some eye-brows? What about the statement the Captain made "

Quote:
What is that
http://nazret.com/blog/index.php/201...rlines-refutes-et-409-crash-report

If this is fully to be blamed on pilot Error then Yes! Shame on Ethiopian for refuting but in this case we shouldn't always be eager to point fingers.


User currently offlineAlias1024 From United States of America, joined Oct 2004, 2777 posts, RR: 2
Reply 17, posted (2 years 6 months 4 weeks 17 hours ago) and read 1819 times:

Quoting Amexair (Reply 17):

The report is very contradicting and quite confusing too.

I did not think so. The report was clear in its conclusion that the crew lost control of the aircraft, but investigators could only speculate on the reasons for the loss of control based on the CVR and DFDR data.

Quoting Amexair (Reply 17):
What puzzles me is that before the final spin towards the ground, the pilots almost lost control of the aircraft two times. Does this not somehow put a question in the head of the pilot in command to really go over his instruments and see what is really happening.

If the pilot was subtlely incapacitated, a possibility suggested in the report, he may have realized things were going wrong but was unable to process the information into a plan of action to stabilize the aircraft. It's also possible that he was having such difficulty that he couldn't even fully realize what state the aircraft was in, much less how to fix the situation.

Quoting Amexair (Reply 17):
The other thing, which no one bothered to mention is

Quote:
Eye witness reports including a Tower controller reported seeing “a light”, “an orange explosion”, “a ball that lasted 2-3 seconds

, or a “ball of fire” around the time of the accident." Does this not raise some eye-brows?

Not really. In almost every accident investigation witnesses always report seeing the airplane on fire before it crashed, regardless of what actually happened. Given the DFDR data, I find it extremely unlikely that there was any kind of onboard explosion or lightning strike before the accident.

This accident follows the same unfortunate trends we see in many accidents. Poor but not terrible weather, fatigue, crew that is not very familiar with each other, captain is PF, first officer is either unable or unwilling to take necessary action to fix the dangerous situation. It also follows a trend of spatial disorientation accidents where crews are taking perfectly good aircraft and putting them in highly unusual attitudes. Needless to say, this is an area that those of us in the industry need to put some emphasis on and figure out why this keeps happening and how to prevent future occurances.



It is a mistake to think you can solve any major problems with just potatoes.
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