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8U Flight 771 Crash: Final Report  
User currently offlineKarelXWB From Netherlands, joined Jul 2012, 12273 posts, RR: 34
Posted (1 year 8 months 5 days 19 hours ago) and read 6782 times:

Remember the 8U Flight 771 crash in Libya? In 2010 an Airbus A330-200 crashed just before landing at Tripoli airport, resulting in 103 fatalities with only 1 survivor (a Dutch boy). The investigation was slowed down due the civil war but the final report has finally been made public today.

The report - 4 pdf files - is now available:
http://caa.ly/en/

The old thread can be found here:
BREAKING: Crash Landing In Tripoli, Libya: (by Flying Belgian May 12 2010 in Civil Aviation)

Quote:

Loss of Flight Path Control in Approach Phase during Go-around

The go-around on 28 April 2010 and the accident flight reveal some apprehension on the part
of PF with regard to the go-around maneuver. Both flights also tend to show that the Captain
was not necessarily comfortable with this procedure either. Even though the crew had to abort
two approaches within two weeks, the go-around was still a flight phase rarely encountered
during operations. In addition, training programs provide mainly type-ratings and go-around
training sessions with one engine inoperative. This raises questions about the low exposure of
crews to go-around maneuvers with all engines operating and with an aircraft becoming lighter
at the end of a flight. From these findings, it is certainly not possible to make generalizations but
many accidents that occurred during missed approaches show the risk associated with this
approach phase.

In addition, during the go-around, it should be noted that neither pilot made callouts in relation
to any deviation of flight parameters. It is likely that neither of them carried out a complete
monitoring of flight parameters such as a pitch attitude of less than 10 degrees or a negative
vertical speed and that their attention was focused on other elements (e.g. the aircraft
configuration).

The approach was conducted with the autopilot connected, the latter being disengaged when
the go-around was initiated, as during the April 28 flight. While it is possible to perform goaround with the autopilot engaged, investigation committee could not determine whether this
behavior is related to crew or to the practices taught, as well as to understand the origin of
these difficulties in controlling the aircraft trajectory during the go-around.
http://oi50.tinypic.com/m8ivza.jpg

http://oi45.tinypic.com/3525ero.jpg

[Edited 2013-02-28 05:24:49]


Only two things are infinite, the universe and human stupidity. And I'm not sure about the universe.
25 replies: All unread, showing first 25:
 
User currently offlineRL757PVD From United States of America, joined Dec 1999, 4697 posts, RR: 11
Reply 1, posted (1 year 8 months 5 days 17 hours ago) and read 6443 times:

Seems like a lot of similar themes to AF 447....


Experience is what you get when what you thought would work out didn't!
User currently onlinebennett123 From United Kingdom, joined Aug 2004, 7707 posts, RR: 3
Reply 2, posted (1 year 8 months 5 days 17 hours ago) and read 6366 times:

"This raises questions about the low exposure of crews to go-around maneuvers with all engines operating and with an aircraft becoming lighter at the end of a flight".

Surely this type of go around is not uncommon at busy airports, (aircraft leaving runway a bit slowly etc).

I understood that pilots have an annual check flight. Might be a good idea to look at the pilot/airline, and say "What type of issues may they not have used recently".

For example, if the pilot normally flies only long sectors, then focus on issues that are more likely to arise on short sectors.


User currently offlineRubberJungle From , joined Dec 1969, posts, RR:
Reply 3, posted (1 year 8 months 5 days 17 hours ago) and read 6245 times:

Flightglobal reporting this:

Illusion and ambiguous control led to Afriqiyah A330 crash

Haven't seen somatogravic illusion mentioned in a report for some time.

[Edited 2013-02-28 07:43:38]

User currently offlineKarelXWB From Netherlands, joined Jul 2012, 12273 posts, RR: 34
Reply 4, posted (1 year 8 months 5 days 16 hours ago) and read 6067 times:

Quoting RubberJungle (Reply 3):

Here is the non-pro version: http://www.flightglobal.com/news/art...ed-to-afriqiyah-a330-crash-382873/



Only two things are infinite, the universe and human stupidity. And I'm not sure about the universe.
User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 5, posted (1 year 8 months 5 days 16 hours ago) and read 6021 times:

First - I applaud the CAA for continuing the investigation and completing the report despite all the turmoil in Lybia over the time between the accident and today. It must have been an especially difficult environment to complete the investigation and report.

Second - I don't remember the discussions of the crash mentioning - hilighting - that the crew had initiated a Go Around. My memory without rereading the entire previous thread is that we assumed the crash was basically landing too short, not a failed missed approach.

From the report

Quote:
3.2 Probable Cause
A final approach carried out in common managed guidance mode should have relieved the crew of their tasks. The limited coordination and cooperation between the two crew members, especially the change into vertical selected guidance mode by the PF, probably led to a lack of a common action plan.

The lack of feedback from the 28 April 2010 flight, flown by the same crew on the same aircraft, did not allow them to anticipate the potential risks associated with managing non-precision approaches.

The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.

During the go-around, the crew was surprised not to acquire visual references. On one hand the crew feared exceeding the aircraft’s speed limits in relation to its configuration, and on the other hand they were feeling the effects of somatogravic illusion due to the aircraft acceleration. This probably explains the aircraft handling inputs, mainly nose-down inputs, applied during the go-around. These inputs were not consistent with what is expected in this flight phase. The degraded CRM did not make it possible for either crew member to identify and recover from the situation before the collision with the ground, even when the TAWS warnings were activated close to the ground.

Based on elements from the investigation, the accident resulted from:

 The lack of common action plan during the approach and a final approach continued below the MDA, without ground visual reference acquired.

 The inappropriate application of flight control inputs during a go- around and on the activation of TAWS warnings,

 The lack of monitoring and controlling of the flight path.

These events can be explained by the following factors:

 Limited CRM on approach that degraded during the missed approach. This degradation was probably amplified by numerous radio-communications during the final approach and the crew’s state of fatigue,

 Aircraft control inputs typical in the occurrence of somatogravic perceptual illusions,

 Inappropriate systematic analysis of flight data and feedback mechanism within the AFRIQIYAH Airways.

 Non adherence to the company operation manual, SOP and standard terminology.

In addition, the investigation committee found the following as contributing factors to the accident:

 Weather available to the crew did not reflect the actual weather situation in the final approach segment at Tripoli International Airport.

 In adequacy of training received by the crew.

 Occupancy of tower frequency by both air and ground movements control.


User currently offlineEPA001 From Netherlands, joined Sep 2006, 4815 posts, RR: 40
Reply 6, posted (1 year 8 months 3 days 19 hours ago) and read 5070 times:
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Quoting RL757PVD (Reply 1):
Seems like a lot of similar themes to AF 447....

Sadly enough that seems to be the case. Crew training, and especially CRM procedures, are still a possibly underestimated element for preparing flight crews for the task at hand.

The strange thing was that this crew went through similar problems just a couple of weeks prior to this fatal landing attempt. The incident was however not officially reported, and as such no further actions were taken. Actions which might have saved lives of the passengers and the crew as we know only 1 young boy survived this horrific crash.


User currently offlinecomorin From United States of America, joined May 2005, 4900 posts, RR: 16
Reply 7, posted (1 year 8 months 3 days 17 hours ago) and read 4858 times:

I am surprised that this thread has not received the attention expected from the a.net pantheon. A ICAO certified, shiny new airliner is flown into the ground by trained pilots - we need help in making sense of this!

While much has been said about the poor quality of third-world training, we have seen the same occur in the case of AF, TK, ET and other tier 1 operations. It seems that well-trained pilots can screw up just as badly as the obviously incompetent PIC on the 8U flight.

I was also confused by the dual controls that provide an 'algebraic sum' input - is that not an odd interface? Are pilots trained to fly an aircraft in tandem?


Thanks


User currently offlinePihero From France, joined Jan 2005, 4610 posts, RR: 77
Reply 8, posted (1 year 8 months 3 days 17 hours ago) and read 4786 times:
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I've just had a quick look at the report.
Human factors / CRM / lack of flight deck communication leading to misunderstandings and different strategic options / lack of x monitoring and FMA call-outs / somatographic illusions... maybe a sticky priority button...
There is, IMHO, a glaring missing part in the report n: the effect on visibility of a rising sun right in the crew's eyes? which made the visual illusion a lot more important.
See on the third thread pictures as from the flight deck of the approach visual conditions ( for added effect, add some mist )
you have it here on post 116

Pending a further more attentive reading, I have to stress the quality of the posts in the previous threads : The scenario, then, was quite well laid out by all participants :
We determined that :

- the crew elected for a non-precision approach on runway 09 although an ILS 27 would have been easier, safer, better manageable for some reasons : visibility, a headwind instead of a 10 kt tailwind, a better understood approach management on an ILS... etc...

- the only explanation of the accident was, as Mandala499 wrote : " a botched go-around attempt... how botched and why it was botched? God knows... and that was a day after the accident.

- A severe somatic illusion was posited, made worse by the long duty hours with minimum rest a last station.

... the report filled in a lot more details on the crew's behaviour... but the A.net team did quite a good job.

Which happens all the time we cooperate...

But I'm sure there are quite a few aspects of the accident that will be discussed.

[Edited 2013-03-02 06:53:14]


Contrail designer
User currently offlinecomorin From United States of America, joined May 2005, 4900 posts, RR: 16
Reply 9, posted (1 year 8 months 3 days 17 hours ago) and read 4749 times:

Quoting Pihero (Reply 8):

Thank you for your post, prayer answered!


Quoting Pihero (Reply 8):
Pending a further more attentive reading, I have to stress the quality of the posts in the previous threads : The scenario, then, was quite well laid out by all participants :
We determined that :

- the crew elected for a non-precision approach on runway 09 although an ILS 27 would have been easier, safer, better manageable for some reasons : visibility, a headwind instead of a 10 kt tailwind, a better understood approach management on an ILS... etc...

- the only explanation of the accident was, as Mandala499 wrote : " a botched go-around attempt... how botched and why it was botched? God knows... and that was a day after the accident.

- A severe somatic illusion was posited, made worse by the long duty hours with minimum rest a last station.

... the report filled in a lot more details on the crew's behaviour... but the A.net team did quite a good job.

  

Frankly, I was quite amazed at the prescience when I read the final report! That's why I was hoping that you guys would help with the postscript.


User currently offlineEPA001 From Netherlands, joined Sep 2006, 4815 posts, RR: 40
Reply 10, posted (1 year 8 months 3 days 15 hours ago) and read 4546 times:
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Quoting Pihero (Reply 8):
but the A.net team did quite a good job.

Which happens all the time we cooperate...

Combined there is quite a level of expertise available here on Airliners.net.  .

Quoting Pihero (Reply 8):
There is, IMHO, a glaring missing part in the report n: the effect on visibility of a rising sun right in the crew's eyes? which made the visual illusion a lot more important.

I missed that element too, especially after heaving read the previous threads. But maybe some reviews of the report might shed some more light on that issue?


User currently offlinefactsonly From Montserrat, joined Aug 2012, 960 posts, RR: 0
Reply 11, posted (1 year 8 months 3 days 15 hours ago) and read 4484 times:

As 71 of the 93 passengers carried the Dutch nationality, the Netherlands Safety Board has supported the Libyan Authorities. The Netherlands Safety Board concurs with the Libyan conclusions and has made a video clip re-enacting the final approach of Afriqiah's A330-200.

To view this video Click on the WINDOWS link under the heading Animatie (animation).



User currently offlinefactsonly From Montserrat, joined Aug 2012, 960 posts, RR: 0
Reply 12, posted (1 year 8 months 3 days 15 hours ago) and read 4446 times:

A.net seems to refuse to accept a link to the Netherlands Safety Board. So here is another link:

www.onderzoeksraad.nl/en/

click on news 1 March 2013.


User currently offlinePihero From France, joined Jan 2005, 4610 posts, RR: 77
Reply 13, posted (1 year 8 months 3 days 11 hours ago) and read 4128 times:
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Quoting comorin (Reply 7):
I was also confused by the dual controls that provide an 'algebraic sum' input - is that not an odd interface? Are pilots trained to fly an aircraft in tandem?

Not really.
An airplane, whatever the design of its flight controls is not supposed to be flown by the two pilots at the same time.
It's a matter of CRM and cockpoit discipline.
As the 'Bus sidesticks action the same computers, it is by design understood that an algebraic summing of both inputs happens when both pilots use the sticks at the same time ; A"dual input" warning occurs in this case.
In order to take over, the captain -or the copilot in extreme cases - could just say in a very assertive tone :"I have control ", something I have said a few times !... On the bus, I will use the priority button on the sidestick : the aircraft wilkl say in a deep voice : "Priority... Left !"
On the report, that captain's button had been tec'd as sticky.
I need to know whether it had an influence on FO's incapability tro regain control from an obviously vertigoed captain.



Contrail designer
User currently offlinehivue From United States of America, joined Feb 2013, 1099 posts, RR: 0
Reply 14, posted (1 year 8 months 3 days 8 hours ago) and read 3843 times:

Quoting Pihero (Reply 13):
On the report, that captain's button had been tec'd as sticky.
I need to know whether it had an influence on FO's incapability tro regain control from an obviously vertigoed captain.

What exactly is the logic behind having priority buttons on Airbus sticks? (I am assuming 777/787 control columns have no comparable feature.) I would think that in the case of dueling inputs "I have control" should be good enough to settle the issue without a mechanical item -- which can fail like any other part -- needing to be thrown into the mix. Or might a button on the captains stick only be a better setup?


User currently offlinePihero From France, joined Jan 2005, 4610 posts, RR: 77
Reply 15, posted (1 year 8 months 3 days 7 hours ago) and read 3795 times:
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Quoting hivue (Reply 14):
I am assuming 777/787 control columns have no comparable feature.

They don't. Their setup is linked controls just like on the other Boeings, with a possibility to break the link with quite a lot of force. on thge T7, as I have no idea on the 78.

Quoting hivue (Reply 14):
"I have control" should be good enough to settle the issue without a mechanical item -- which can fail like any other part

Yes and no. One has to think of the possibility of a stick failure on one side : The LH flight in which someone managed to mount the captain's stick backward. The FO took over with his own side which was working normally. there have been too many accidents due to x mounting of the flight controls... In this case, the 'Bus setup saved the day.

By the way, I read the captain's sticky priority button effect on the accident, and it had been dismissed by the investigation as an accessory cause.

It seems that all of it bopiled down to human factors.

But there is still an awful lot to study.



Contrail designer
User currently offlineflyingturtle From Switzerland, joined Oct 2011, 2445 posts, RR: 14
Reply 16, posted (1 year 8 months 3 days 7 hours ago) and read 3761 times:

Quoting hivue (Reply 14):
What exactly is the logic behind having priority buttons on Airbus sticks?

One reason has been discussed in the aftermath of AF447, and it is quite logical. With control columns, dexterity of your hands is not of importance. But in Airbii with sidesticks, the FO will often be able to override the Captain because the Captain has to use his left hand on the sidestick.

To make a level playing field, the priority switch has been invented. This also helps when one of the pilots would lose consciousness, but is still pushing on the stick with his body weight.


David



Keeping calm is terrorism against those who want to live in fear.
User currently offlinehivue From United States of America, joined Feb 2013, 1099 posts, RR: 0
Reply 17, posted (1 year 8 months 3 days 6 hours ago) and read 3678 times:

Quoting Pihero (Reply 15):
been too many accidents due to x mounting of the flight controls... In this case, the 'Bus setup saved the day.

Sounds like it did. But cross connecting controls? Back in the day, yeah, but I wouldn't have thought the computers on a FBW airplane would have let that sneak by. Very interesting.

Quoting flyingturtle (Reply 16):
This also helps when one of the pilots would lose consciousness, but is still pushing on the stick with his body weight.

Hmmm. Same thing could happen on a 777/787. I get more impressed with AB's side stick approach the more I hear about it.


User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 18, posted (1 year 8 months 3 days 6 hours ago) and read 3677 times:

Quoting flyingturtle (Reply 16):
This also helps when one of the pilots would lose consciousness, but is still pushing on the stick with his body weight.

There have been a couple instances where the weight of a disabled pilot's body has made it impossible to pull back in a yoke aircraft. Mostly in small GA, but I think I remember an old story about almost losing a B727 for that reason.


User currently offlinecomorin From United States of America, joined May 2005, 4900 posts, RR: 16
Reply 19, posted (1 year 8 months 3 days 6 hours ago) and read 3634 times:

Pihero and others, thanks for the explanations.

The report doesn't seem to address the sunrise glare effect, but does say that the call from the pilot of the aircraft on the ground advising of low cloud may have 'destabilized' the PIC.

Just one question, I thought when you hit the GA button the aircraft automation just takes over - throttles, attitude etc - but in the report the crew disconnects the A/P and flies manually.


User currently offlinePihero From France, joined Jan 2005, 4610 posts, RR: 77
Reply 20, posted (1 year 8 months 3 days 5 hours ago) and read 3575 times:
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Quoting comorin (Reply 19):
ust one question, I thought when you hit the GA button the aircraft automation just takes over - throttles, attitude etc - but in the report the crew disconnects the A/P and flies manually.

It's one of the questions that need to be cleared. I've just finished some paperwork and was about to go to bed ).
It doesn't seem to be an A/P disconnect by the system ( it does so if airplane is below MDA - 50ft, i.e; 570 ft ). I understand the PF did it by pressing the button, (same button does the priority takeover )... it doesn't seem to be company procedure as the crew workload is increased in a very important way on a manual go around, especially for a crew that unprepared.
will be back.
Ah !
As for the sunrise blinding effect when looking into the sunrise, please see the picture that oly720man worked from Google on post 168 and [b]nnomad[|/b] photoshopped on post #182 of the second thread. one could upload it again onto this one.
That thread is here

[Edited 2013-03-02 18:50:11]


Contrail designer
User currently offlineMCOflyer From United States of America, joined Jun 2006, 8683 posts, RR: 16
Reply 21, posted (1 year 8 months 3 days 4 hours ago) and read 3484 times:

Quoting rfields5421 (Reply 18):

There have been a couple instances where the weight of a disabled pilot's body has made it impossible to pull back in a yoke aircraft. Mostly in small GA, but I think I remember an old story about almost losing a B727 for that reason.

A flying Tigers L1049 Constellation crashed on approach to Burbank and lost all crew because of this reason. There was no way the co-pilot could have regained control because the captain was slumped on the control collum due to a heart attack.

KH



Never be afraid to stand up for who you are.
User currently offlineViscount724 From Switzerland, joined Oct 2006, 25700 posts, RR: 22
Reply 22, posted (1 year 8 months 3 days 2 hours ago) and read 3371 times:

Quoting comorin (Reply 19):
The report doesn't seem to address the sunrise glare effect,

The report does mention that the crash occurred 10 minutes before official sunrise.


User currently offlineRubberJungle From , joined Dec 1969, posts, RR:
Reply 23, posted (1 year 8 months 2 days 23 hours ago) and read 3200 times:

Quoting Viscount724 (Reply 22):

The report does mention that the crash occurred 10 minutes before official sunrise.

It's a little ambiguous about the effects.

Sunrise is defined as the point at which the upper edge of the Sun's disk touches the horizon. Sunrise in Tripoli was about 06:10 and the crash occurred just after 6:01.

For an aircraft at altitude, sunrise comes earlier, but since the aircraft only turned towards the east some three minutes before the accident, and was flying below 1,500ft, the effect on sunrise time would have been limited.

However, this follow-up article to the one posted earlier also features animation from the Dutch Safety Board that includes an impression of the sunlight:

http://www.flightglobal.com/news/art...-explain-premature-descent-382937/


User currently offlineltbewr From United States of America, joined Jan 2004, 13148 posts, RR: 15
Reply 24, posted (1 year 8 months 2 days 22 hours ago) and read 3087 times:

I appreciate the animation of the final approach and crash done by the Netherlands authorities involved, it makes it easier for the non-pilots to understand what happened a lot easier.

I notice that apparently the topography for miles around the airport is very flat with few if any visual cues as to altitude or markers where the key points of where the final decent glide path is set. This was apparently made worse by the pre-dawn haze. You have a PIC/FO who apparently made a similar misjudgment in the same or similar a/c at the same airport but were able to do a go-round in time, so shouldn't they have been more aware of when they had to set the final glide path?

My further question is this: why didn't the PIC pull up the a/c and do a go-round when they got the ground proximity warning ?


User currently offlineflyingturtle From Switzerland, joined Oct 2011, 2445 posts, RR: 14
Reply 25, posted (1 year 8 months 2 days 16 hours ago) and read 2806 times:

Did you already notice the comments by the Dutch Onderzoeksraad to the Libyan accident report?

(Can't post the link, it will wreck the posting and a.net will go down in flames.)

Among others, they point to
- there is nothing on how the government inspected the airline, and how Afriqiah organizes the training
- CRM issues, like the practice of the non-flying captain making control inputs
- crew fatigue was not appropriately addressed
- the role of the relief pilot is not addressed


David



Keeping calm is terrorism against those who want to live in fear.
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