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Go-around Incident, What Happens To The Crew?  
User currently offlineMerlinIIIB From Norway, joined Aug 2005, 121 posts, RR: 0
Posted (8 years 5 months 1 week 7 hours ago) and read 6574 times:

First of all, I would like to apologise for this long post. A friend of mine was a passenger on board a B757 flight which performed a go-around that went terribly wrong. He is still affected by this incident, and he wonders: What happens to the crew after this kind of event - how will "the system" deal with them?

Transcript from the official report (events taking place after an unstable approach in IMC):

= = =

When the go-around manoeuvre was started by the use of the auto go-around system, the speed was 182 kt. The aircraft was flown manually. The aircraft pitch was increased to approx. 20deg and the aircraft started to climb. Upon initiating the go-around, the A/T automatically engaged and increased the thrust to the EPR (Engine Pressure Ratio) limit. In addition, the application of the under wing engine power also gave pitch up movement. During the climb the landing gear was retracted. The flight director pitch initially targeted a pitch attitude of 15deg. The airspeed reached a maximum of 198 kt before it started to decrease.

Because of the aircrafts proximity to the MCP selected altitude of 2 500 ft when the go-around was started; the AFDS transitioned to Altitude Capture almost immediately after a positive rate of climb was achieved. At time XX:XX:XX UTC the aircraft climbed rapidly through the MCP altitude of 2 500 ft, The FD continued to give commands targeting the MCP selected altitude. The A/T changed from go-around mode to targeting the MCP selected speed (150 kt). The maximum aircraft pitch (21deg) was reached. The thrust remained near maximum because the Commander held the throttles forward. The speed was decelerating and quickly dropped below MCP speed. The pitch flight director continued to give command to lead the pilot back to the MCP altitude.

The aircraft reached a peak altitude of 2895 ft (FDR QNH corrected altitude) and the speed had decreased to 137 kt. (The reference speed for flaps 20 is 131 kt.) Nose down was applied manually by the control column. The First Officer called for “bug up” (for the flap up manoeuvring speed) to set the airspeed indicator, and the Commander pushed on the Flight Level Change Switch (FLCH) button to break the flight director altitude lock on. The speed selected on MCP was changed from 150 kt to 210 kt. During the next seconds, a full nose down input on the control column was made manually. The aircraft pitched over to an attitude of approx. –30deg, and for a period of approx. 5 seconds the FDR indicates negative g-values with a maximum load factor of –0.6 g.

The control column was briefly returned to near neutral, and then another abrupt large nose down column input was made. The aircraft pitched over rapidly with the speed increasing excessively. The FDR data show that the Ground Proximity Warning System (GWPS) aural warning of “Pull up” was activated. The aircraft was now in a steep dive and rapidly descending. During the dive the flight director pitch bar gave pitch up commands relative to the pitch attitude. The A/T reduced the trust from 98% N1 to 45% N1. At time xx:xx:xx UTC the aircraft pitch attitude had peaked at -49deg and was beginning to increase positively.

At this time the First Officer called out “PULL UP!” - “PULL UP!”. The GPWS aural warnings of “TERRAIN” and then “TOO LOW TERRAIN” were activated. Both pilots were active at the control columns and a maximum “up” input was made. A split between left and right elevator was indicated at this time. It appears the split occurred due to both pilots being active at the controls. The pilots did not register the aural warnings. During the dive the airspeed increased to 251 kt and the lowest altitude in the recovery was 321 ft radio altitude with a peaked load factor of +3.59 g’s.

The recovery continued with the aircraft pitch attitude increasing to about 40deg, and a positive rate of climb was established. The AT increased the thrust back to around 98% N1. Eventually a normal trimmed flight was established, after a short level off around 3 000 ft, finally at 4 000 ft, after several abrupt control inputs.

( Findings...)

The importance of crew cooperation is imperative. In this case, the board is of the opinion there was a complete breakdown of crew management and a lack of interaction at an early stage. When the confusion started, the combination of one pilot manually operating the controls partly in opposition to the automatic throttle movement made this “upset” understandable. This can be referred to as an “automation trap”. When “bug-up” is selected to target speed, this command gets cancelled by selection of “Flight Level Change” or by altitude capture. The speed then becomes “present speed”. This caused the aircraft to act differently than the pilots had anticipated. This resulted in confusion and was probably a factor in causing the incident to occur. In the opinion of the board it is not satisfactory that a seemingly properly trained and qualified airline crew should end up loosing control of a modern airliner and cause an incident like this one.

23 replies: All unread, jump to last
 
User currently offlineKaddyuk From Wallis and Futuna, joined Nov 2001, 4126 posts, RR: 25
Reply 1, posted (8 years 5 months 1 week 6 hours ago) and read 6562 times:

Quoting MerlinIIIB (Thread starter):
how will "the system" deal with them?

Suspension of ratings and permission to fly is likely. Re-Training and Re-Evaluation is probable. They could loose their jobs and tickets, however i think all airlines would look into trying to prevent further incident rather than just sacking any pilot(s) which made a mistake.



Whoever said "laughter is the best medicine" never had Gonorrhea
User currently offlineBobster2 From , joined Dec 1969, posts, RR:
Reply 2, posted (8 years 5 months 1 week 5 hours ago) and read 6524 times:

Wow. I found the complete report on Google.
http://www.rnf.is/media/skyrslur/200...22._januar_2002._(Endurutgafa).pdf

Perhaps the worst part of the story is that the airplane remained in service and was not inspected for damage until the C-check the following month. It turned out that the incident didn't cause any damage to the plane, but the fact that the airline didn't care enough to take the plane out of service is troubling. It did require careful inspection and precautionary replacement of certain parts.

Also, the investigation into the incident was partly in response to letters from "concerned passengers". The airline was not volunteering any information about the seriousness of the incident until they were forced to.

[Edited 2006-04-14 23:18:26]

User currently offlineRedcordes From United States of America, joined Jan 2006, 245 posts, RR: 0
Reply 3, posted (8 years 5 months 1 week 5 hours ago) and read 6494 times:

Wow, that must have been one heck of a ride--like a roller coaster but much, much more frightening! And, 3.6 g's sounds like a lot. I doubt any thrill-rides even approach that g-force and to an older, or person in poor condition/health, that could be traumatic physically as well as mentally.


"The only source of knowledge is experience." A. Einstein "Science w/o religion is lame. Religion w/o science is blind."
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 41
Reply 4, posted (8 years 5 months 1 week 4 hours ago) and read 6467 times:

This is the kind of situation that a few around here seem to think can only happen to aircraft from "another manufacturer". I wasn't aware of this incident - interesting. Glad I wasn't on it.

User currently offlineBobster2 From , joined Dec 1969, posts, RR:
Reply 5, posted (8 years 5 months 1 week 4 hours ago) and read 6457 times:

It reminds me of the Gulf Air crash in Bahrain. The captain went into a "mental overload situation" during an unstable approach and go-around, the first officer was "somewhat passive and confused". In this case the F/O took action when the pitch was -49 degrees, in the other case the F/O didn't.

User currently offlineGrbld From Netherlands, joined Dec 2005, 353 posts, RR: 3
Reply 6, posted (8 years 5 months 1 week 3 hours ago) and read 6434 times:

Quoting David L (Reply 4):
This is the kind of situation that a few around here seem to think can only happen to aircraft from "another manufacturer".

Actually, the plane was hand flown all the way apparently, and some MAJOR overcorrecting took place. Even though it reads "the airplane climbed rapidly", it was the pilot flying that did it. The first press of the GA button on a 757 gives a reduced go-around thrust, which gives you a very decent 1000-2000 fpm rate of climb. Press it again, and you'll get full thrust on that powerful baby.

A go-around is a standard maneuver, in fact any approach should be expected to end in a go-around, unless a safe landing is assured. In the public's eye, a go-around is always very dramatic, but it isn't really. But I guess the pilots in question were startled here as well, which is odd. This, compared with major overcorrecting (-49 degrees of pitch!?!?) sounds like inexperience. But who knows!


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 41
Reply 7, posted (8 years 5 months 1 week 2 hours ago) and read 6412 times:

Quoting Grbld (Reply 6):
Actually, the plane was hand flown all the way apparently, and some MAJOR overcorrecting took place

True but in previous discussions some argued that manual "override" was simple in anything but an Airbus.


User currently offlineAirWillie6475 From United States of America, joined Jan 2005, 2448 posts, RR: 1
Reply 8, posted (8 years 5 months 6 days 19 hours ago) and read 6308 times:

Quoting Redcordes (Reply 3):
Wow, that must have been one heck of a ride--like a roller coaster but much, much more frightening! And, 3.6 g's sounds like a lot. I doubt any thrill-rides even approach that g-force and to an older, or person in poor condition/health, that could be traumatic physically as well as mentally.

A normal person/elderly can stand a +g force of up to 4. The human body however, cannot handle more than -1g.


User currently offlineBellerophon From United Kingdom, joined May 2002, 583 posts, RR: 59
Reply 9, posted (8 years 5 months 6 days 15 hours ago) and read 6254 times:

AirWillie6475

...The human body however, cannot handle more than -1g....

Not correct, in fact the human body can handle a lot more than -1g.

Ask any aerobatic pilot who flies a Pitts, Cap, Lazer, Extra, Sukoi etc what their "g" meter reads at the end of a display.

Regards

Bellerophon


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 41
Reply 10, posted (8 years 5 months 6 days 15 hours ago) and read 6236 times:

Quoting Bellerophon (Reply 9):
Not correct, in fact the human body can handle a lot more than -1g.

Ask any aerobatic pilot who flies a Pitts, Cap, Lazer, Extra, Sukoi etc what their "g" meter reads at the end of a display.

Indeed, I wouldn't say someone doing a handstand was exactly teetering on the edge!


User currently offlineKaddyuk From Wallis and Futuna, joined Nov 2001, 4126 posts, RR: 25
Reply 11, posted (8 years 5 months 6 days 15 hours ago) and read 6231 times:

Quoting Bellerophon (Reply 9):
Not correct, in fact the human body can handle a lot more than -1g.

The body does not handle negative Gee forces well... Upto about a maximum of negative 3 (-3g). This is because neg Gee's force blood up into the head and exert pressure on the brain and eye capilliaries (which is why you "red-out" during neg G manouvers).



Whoever said "laughter is the best medicine" never had Gonorrhea
User currently offlineStarlionblue From Greenland, joined Feb 2004, 17038 posts, RR: 66
Reply 12, posted (8 years 5 months 6 days 14 hours ago) and read 6227 times:

Quoting David L (Reply 4):
This is the kind of situation that a few around here seem to think can only happen to aircraft from "another manufacturer".

One of my first thoughts was exactly this. It raises the important point that "even Boeing" aircraft have automation which can "override" the pilots if they make mistakes.

Quoting AirWillie6475 (Reply 8):
A normal person/elderly can stand a +g force of up to 4. The human body however, cannot handle more than -1g.

You may be able to handle 4g, but believe me you'll wish you didn't. For an untrained person, tunnel vision and powerful discomfort will be felt if 4g is sustained for more than a very brief period.

Same with negatives, and as has been said -1 is not a problem.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlinePihero From France, joined Jan 2005, 4445 posts, RR: 76
Reply 13, posted (8 years 5 months 6 days 14 hours ago) and read 6221 times:
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NAV20, WHERE ARE YOU ????????
WE NEED YOUR EXPERTISE !!!!



Contrail designer
User currently offlineStarlionblue From Greenland, joined Feb 2004, 17038 posts, RR: 66
Reply 14, posted (8 years 5 months 6 days 14 hours ago) and read 6209 times:

Quoting Pihero (Reply 13):
NAV20, WHERE ARE YOU ????????
WE NEED YOUR EXPERTISE !!!!

LOL. I was afraid to say it. But I dare say I will be linking this thread when we run into him again.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 41
Reply 15, posted (8 years 5 months 6 days 13 hours ago) and read 6203 times:

Quoting Starlionblue (Reply 14):
Quoting Pihero (Reply 13):
NAV20, WHERE ARE YOU ????????
WE NEED YOUR EXPERTISE !!!!

LOL. I was afraid to say it. But I dare say I will be linking this thread when we run into him again.

Yup. It's in my little black book!


User currently offlineMerlinIIIB From Norway, joined Aug 2005, 121 posts, RR: 0
Reply 16, posted (8 years 5 months 6 days 11 hours ago) and read 6153 times:

Quoting Bobster2 (Reply 2):
Wow. I found the complete report on Google

Well, it was not my intention to focus on a particular airline or crew in the original post. My friend, who was on the aircraft, wanted to know what the pilots must go through after this kind of event, in which pilot judgement and handling was the major part in the findings and recommendations.

Detailed information concerning actions the crew will experience from their organisation and from authorities after this type of event is most welcome.


User currently offlineViv From Ireland, joined May 2005, 3142 posts, RR: 28
Reply 17, posted (8 years 5 months 6 days 10 hours ago) and read 6144 times:

Quoting AirWillie6475 (Reply 8):
The human body however, cannot handle more than -1g.

What nonsense! Go back to school, pal.



Nikon D700, Nikkor 80-400, Fuji X Pro 1, Fujinon 35 f/1.4, Fujinon 18 f/2
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 41
Reply 18, posted (8 years 5 months 6 days 9 hours ago) and read 6128 times:

Quoting MerlinIIIB (Reply 16):
My friend, who was on the aircraft, wanted to know what the pilots must go through after this kind of event,

Another thread hijack - sorry!


User currently offlineStarlionblue From Greenland, joined Feb 2004, 17038 posts, RR: 66
Reply 19, posted (8 years 5 months 5 days 12 hours ago) and read 5912 times:

Quoting MerlinIIIB (Reply 16):

Well, it was not my intention to focus on a particular airline or crew in the original post. My friend, who was on the aircraft, wanted to know what the pilots must go through after this kind of event, in which pilot judgement and handling was the major part in the findings and recommendations.

I don't know the particulars, but it's important to remember that if the crew wasn't being criminally negligent, the objective should be both to discipline them and to ensure that they, the airline, and the aviation community at large learn from their mistakes.

If they have the right personality, they will come out of the incident better pilots than they were before.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineMerlinIIIB From Norway, joined Aug 2005, 121 posts, RR: 0
Reply 20, posted (8 years 5 months 3 days 10 hours ago) and read 5604 times:

Quoting Bobster2 (Reply 5):
It reminds me of the Gulf Air crash in Bahrain. The captain went into a "mental overload situation" during an unstable approach and go-around, the first officer was "somewhat passive and confused".

When a captain experience a passive, non-participating first officer on initial approach, what should he do? Request a go-around and address the problem before a 2nd landing attempt, or perform the approach himself and address the issue with the FO after landing?

Some years ago a 747 captain told me that he had performed what he considered a "single pilot" operation into JFK due to a passive first officer.

What is acceptable CRM, and what is regarded as unnaceptable?


User currently offlineSlamClick From United States of America, joined Nov 2003, 10062 posts, RR: 68
Reply 21, posted (8 years 5 months 3 days 10 hours ago) and read 5594 times:

Terrifying!

Quoting Starlionblue (Reply 19):
but it's important to remember that if the crew wasn't being criminally negligent

Exactly right. However, it does appear to have been an unacceptable perfomance that nearly caused a crash and something must be done about it. My attitude toward the crew would not be punitive, but corrective. That sort of thing just cannot happen. I'm thinking a serious carpet dance, maybe being placed back on probation, and a requal simulator series before they return to the line. Also a self-disclosure and/or NASA report on the part of the Company and the crew.

A missed approach in a very lightly loaded hotrod like the 757 is a very demanding maneuver. I make a point of thinking quickly through the sequence of steps before starting down final. The rule: "Select the appropriate level of automation." is never more pertinent than in this situation.

If need be, punch off all automation, command the altidude to be set and the speed you want bugged (not just 'bug me' but specify a number) Rein it all in, take a deep breath and start putting the auto stuff back on. Maybe!

Or, if you are so minded, do it on A/P A/T but don't forget who is flying the machine! The autopilot is fearless. It will cheerfully kill you if you don't program it right. Watch the FMA! You pushing buttons is same as you sitting on Santa's lap. The captions on the FMA are the goodies under the tree.

Quoting MerlinIIIB (Reply 20):
What is acceptable CRM, and what is regarded as unnaceptable?

Acceptable: Anything that tends to correct the situation. Hint: Don't crash!Commands at such a time as this should be clear and unambiguous. "Set speed 200 knots" instead of "bug me" and so on.

Unacceptable: Anything that undermines the proper conduct of the flight. Order is your friend. Chaos and discord are not.



Happiness is not seeing another trite Ste. Maarten photo all week long.
User currently offlineMerlinIIIB From Norway, joined Aug 2005, 121 posts, RR: 0
Reply 22, posted (8 years 5 months 3 days 6 hours ago) and read 5510 times:

Quoting SlamClick (Reply 21):
However, it does appear to have been an unacceptable perfomance that nearly caused a crash and something must be done about it.

Thanks, SlamClick. I understand that you have read the full incident report, and based on your assessment, my friend who was on-board that flight now can assume that proper actions have indeed been taken with respect to the crew.

After all, the airline involved still has an excellent reputation and I believe they want to keep it that way. The incident report is really great reading for those who want to study CRM (or lack of it).

Quoting MerlinIIIB (Reply 20):
When a captain experiences a passive, non-participating first officer on initial approach, what should he do?

Still curious about the above question, Slam, what would you do?


User currently offlineSlamClick From United States of America, joined Nov 2003, 10062 posts, RR: 68
Reply 23, posted (8 years 5 months 3 days 4 hours ago) and read 5465 times:

Quoting MerlinIIIB (Reply 20):
Some years ago a 747 captain told me that he had performed what he considered a "single pilot" operation into JFK due to a passive first officer.



Quoting MerlinIIIB (Reply 22):
Still curious about the above question, Slam, what would you do?

For the past few years the airlines have had a "partial incapacitation" drill in the simulator. It works like this: As we are about to begin an approach, the sim instructor leans up and says to me (I'm the PNF) to become unresponsive. So the guy hits that point on the approach and commands "Gear down, flaps 25 or some such" and I just stare out the window. I miss callouts, radio calls and so on. (I'm good at being subtly incapacitated, I think I'm going to be good at senility too!)

For the PF it is just one more thing to handle. He can reach the gear and flap handles, he has a microphone on his side. From the marker inbound we can all solo one of these things. The big thing is, don't let the incapacitated or unresponsive (or dead) crewmember be the cause of an incident. The plane must be flown.

So we might put our own gear down and we might become increasingly assertive to break through to the other crewmember. It is a different sort of situation than we are used to but the rules are still very much the same

1. Aviate
2. Navigate
3. Communicate

So whatever it takes.

If the guy is having a stroke, then getting the thing on the ground on the first pass might be the only thing that will save his life. You were all set up and caught up at the moment he stopped responding, so just expand your own sphere of awareness a bit and keep it all going. Abnormals are all about getting things back to normal to the greatest degree possible.



Happiness is not seeing another trite Ste. Maarten photo all week long.
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