NZ747
Topic Author
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Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:22 am

hey guys

I'm currently doing a crew resource management assignment on hazardous attitudes and my question is (that I need help on);

what major air disasters have resulted due to hazardous crew attitudes that have compromised safety of the flight?

Feed back will be much appreciated.

Thanks in advance
NZ747  

[Edited 2006-11-27 01:24:42]
 
ChiGB1973
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RE: Air Crashes Caused By Hazardous Crew Attitudes

Mon Nov 27, 2006 9:29 am

There is this one:

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20041015X01633&key=1

I'd have to look and find some, but it seems there are many that are a result of bad CRM rather than hazardous attitudes.

M
 
swissy
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:42 am

If you are talking about "careless" there would be the Aeroflot Airbus....
there are other ones I myself consider somewhat "careless" crews which resulted in fatalities and there is always the NTSB web site....

Cheers,
 
ikramerica
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:43 am

I think the premise is sound, as the rate of crashes have declined as the technology in place to prevent crew from doing something wrong has grown more sophisticated. Other than bad maintenance, planes in the developed world are crashing now only when pilots make decisions the plane can't prevent them from making (or ATC screws up). Taking off/landing from the wrong runway, refusing to divert in bad weather, being vectored into each other, flying without a transponder, being spaced too closely by ATC.

If we can eliminate those mistakes, crashes of properly maintained aircraft would be nearly eliminated.
Of all the things to worry about... the Wookie has no pants.
 
OPNLguy
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RE: Air Crashes Due To Hazardous Crew Attitudes (H

Mon Nov 27, 2006 9:46 am

As long as it's not due tomorrow and you have a little time for some library research, try this:

1. Get a copy of the NTSB report on Air Florida 90 (737 taking off from DCA in a snow storm), which crashed in January 1982. It's available online and I'll re-edit this message once I find a link. Use it to get familiar with the accident. Then...

2. At the library, look up a couple magazine articles from later in 1982 (Oct or Nov, I think), in Science Digest and Psychology Today. Both magazines had articles related to airline safety and aeronautical decsionmaking, but one great article in particular was the one written by Robert Trivers and Huey Newton. Both guys were biologists, not aviation experts, and they discuss the crew aspects of the Air Florida accident in great detail, especially where it came to reality-evasion and self-deception.

I worked for Air Florida at the time, and knowing both pilots, I thought the observations in the Trivers/Newton article were spot-on. I think the article should be required reading for anyone connected with flight operations.

Good luck!
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
jetdeltamsy
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:47 am

The American Airlines crash at Little Rock takes the cake for me.

The pilot was a real cowboy. Too bad he died.
Tired of airline bankruptcies....EA/PA/TW and finally DL.
 
OPNLguy
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RE: Air Crashes Due To Hazardous Crew Attitudes (H

Mon Nov 27, 2006 9:58 am

Quoting Jetdeltamsy (Reply 5):
The American Airlines crash at Little Rock takes the cake for me.

The pilot was a real cowboy. Too bad he died.

I always saw that one as another example of the self-deceptive and reality evasive behavior I refered to previously.

Case in point, they're on approach and the RVR drops below landing minimums, and the F/O announces such. The captain says that they're inside the final approach fix and, indeed they are, and can continue the approach.

What this didn't consider was exactly what was causing the reduced visibility as expressed in RVR. If it'd been fog that was driving the reduced RVR, it'd have been no problem, but the RVR was being driven down by heavy rain from the thunderstorm cell attacking the airport from the northwest side. Put another way, it could have been RVR 3000 in ping pong balls or RVR 3000 in bowling balls, and one's no problem and the other is a big problem. By focusing on the RVR value itself and not what was causing it, the PIC saw want he wanted to see, and we know what happened...
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
Coronado990
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:01 am

The one that will always stick in my mind is the KAL flight in Guam back in AUG 1997 because our agency had two passengers on the flight that never came home...

On August 6, 1997, about 0142:26 Guam local time, Korean Air flight 801, a Boeing 747-3B5B (747-300), Korean registration HL7468, operated by Korean Air Company, Ltd., crashed at Nimitz Hill, Guam. Flight 801 departed from Kimpo International Airport, Seoul, Korea, with 2 pilots, 1 flight engineer, 14 flight attendants, and 237 passengers on board. The airplane had been cleared to land on runway 6 Left at A.B. Won Guam International Airport, Agana, Guam, and crashed into high terrain about 3 miles southwest of the airport. Of the 254 persons on board, 228 were killed, and 23 passengers and 3 flight attendants survived the accident with serious injuries. The airplane was destroyed by impact forces and postcrash fire. Flight 801 was operating in U.S. airspace as a regularly scheduled international passenger service flight under the convention on International Civil Aviation and the provisions of 14 Code of Federal Regulations Part 1239 and was on an instrument flight rules flight plan.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

the captain's failure to adequately brief and execute the nonprecision approach and the first officer's and flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach. Contributing to these failures were the captain's fatigue and Korean Air’s inadequate flight crew training. Contributing to the accident was the Federal Aviation Administration's (FAA) intentional inhibition of the minimum safe altitude warning system (MSAW) at Guam and the agency's failure to adequately manage the system.
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NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:11 am

Quoting NZ747 (Thread starter):
hazardous crew attitudes that have compromised safety of the flight?

NZ747, I can think of three accidents offhand where 'hazardous crew attitudes' CONTRIBUTED to accidents. But they were not the SOLE cause - nor would one expect them to be, since virtually all accidents are found to have had multiple contributory causes.

A further complication is that there is almost always a big element of uncertainty as to what really happened, especially in 'all killed' accidents.

The three that immediately come to mind are:-

1. KLM/PanAm Teneriffe - impatience on the part of the KLM pilot. However contributing causes were fog, inexpert Air Traffic Control, and radio interference.

2. Aeroflot 593 - the pilot let his kids 'fly' the aeroplane. Contributing causes were thought to have been lack of a 'mode change' warning system on the autopilot and inadequate 'upset recovery' training.

3. American 587 - the 'pilot flying' (First Officer) was unhappy about following too close behind a 'heavy' that had just taken off, but the Captain told him to proceed; and they ran into wake turbulence. Other contributing causes are thought to have included pilot error, over-sensitive rudder controls, inadequate training, and (on recent evidence) possible weakening of the rudder structure due to chemical contamination.

If any of those three would fit your bill I'd be happy to look out details/links for you.

[Edited 2006-11-27 02:46:41]
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
teneriffe77
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:17 am

The 1974 Eastern DC9 accident at CLT is another example where the NTSB determined that the cause was "The National Transportation Safety Board determines that the probable cause of the accident was the flightcrew’s lack of altitude awareness at critical points during the approach due to poor cockpit discipline in that the crew did not follow prescribed procedures."
http://aviation-safety.net/database/record.php?id=19740911-1&lang=en
 
redngold
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:36 am

You could also consider Eastern Airlines Flight 401, an L1011 crash in the Florida Everglades outside of Miami, Florida in 1972. The crew were working together on a problem with an indicator light and lost track of the aircraft's altitude; by the time someone realized their mistake, they were less than 100 ft AGL and the plane crashed. A major contributing factor was a design flaw which allowed the autopilot to be disconnected on the copilot's yoke.

http://aviation-safety.net/database/record.php?id=19721229-0&lang=en
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MCOflyer
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:51 am

Aeroflot 593? Havent heard that one.

MCOflyer
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N702ML
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:57 am

I recall one training class in Crew Resource Management when the crash of the Air Ontario F28 in snowy condition was discussed.....

The "attitude" of a commuting or deadheading pilot was that it was not his place to mention to the pilots that he thought there was snow/ice on the wings.

If I recall correctly, he survived and still testified that he would not have changed a thing about what he did: the pilot in command is the pilot in command and you do not question him or her.
The opinions expressed are my own and do not necessarily reflect those of Southwest Airlines.
 
NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:14 am

Quoting MCOflyer (Reply 11):
Aeroflot 593? Havent heard that one.

Pretty well-known case, MCOflyer:-

http://en.wikipedia.org/wiki/Aeroflot_Flight_593
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
MCOflyer
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:23 am

I didn't know about it. My bad.

MCOflyer
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UN_B732
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:34 am

Don't forget Pinnacle 3701, the only reason that plane went down was because the crew were "pushing it to the limit"
The CVR really attests to how laid back that cockpit sounded.
What now?
 
sstsomeday
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:52 am

Quoting NAV20 (Reply 8):
1. KLM/PanAm Teneriffe - impatience on the part of the KLM pilot. However contributing causes were fog, inexpert Air Traffic Control, and radio interference.

Yes.

The others that spring to mind are:

2) a NW ferry flight of a CRJ in which the two pilots (no passengers) tried, for fun, to take the A/C to it's absolute operational height. The engines flamed out and they were not able to be restarted for technical reasons that escape me. Both pilots perished. There is a very sad transcript of them realising their dilemma and trying desperately to get out of it. I suggest a google search.

3) I recall AC had a 767 run out of fuel about 20 years ago and glide to a landing on a closed airport runway because of confusion at fueling between kilograms and pounds. It landed at Gimli Industrial Park Airport (which I believe was being used that day for drag racing) under no power, so it was then nicknamed the Gimli Glider. However - I don't think that this can be fairly attributed to "recklessness." Besides, some pretty heroic flying saved the passengers.


http://en.wikipedia.org/wiki/Gimli_Glider
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abrelosojos
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:58 am

Dont forget the utterly moronic incompetent crews of:

1/ SV 163: http://en.wikipedia.org/wiki/Saudia_Flight_163
2/ AV 52: http://en.wikipedia.org/wiki/Avianca_Flight_52

Good luck with the project.

Cheers,
A.
Live, and let live.
 
Tg 747-300
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 12:00 pm

What about the Western Dc-10 wher the crew started experimenting with the engines during cruise..

tg 747-300
intentionally left blank
 
NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 12:33 pm

NZ747, in case it helps, it looks as if 'impatience' is quite a frequent feature of such accidents. It's not often mentioned, but pilots are often chided by their alrines for not 'keeping to schedule', which is pretty hard on them since so many factors outside their control can lead to delays.

This factor is fairly clearly shown in the CVR transcripts of two of the accidents I mentioned:-

AA587 (HOT2 is First Officer, HOT1 is Captain) - if they'd waited a few seconds the accident might not have happened:-

0912:40
HOT-2 lights to go. I'm gonna make... left turn two twenty. go out the
Bridge five thousand feet's the top. if we have a problem, I'll
clean it up at six.... ten.... left traffic for this runway....
0913:05
TWR Japan Air forty seven heavy, fly the Bridge Cimb, contact New
York departure, good morning.
0913:10
JAL47 Bridge Climb, switch to departure, Japan Air four seven, good
morning.
0913:21
HOT-1 you have the airplane.
HOT-2 I got the brakes.
0913:22
HOT-1 I have the radios.
0913:27.6
TWR American five eight seven heavy, wind three zero zero at
niner, runway three one left, cleared for takeoff.
0913:31.7
RDO-1 cleared for takeoff, American ah, five eight seven heavy.
0913:35.3
HOT-2 you happy with that distance?
0913:38.5
HOT-1 aah, he's.... we'll be all right once we get rollin'. he's supposed
to be five miles by the time we're airborne, that's the idea.
0913:45.5
HOT-2 so you're happy. lights?
0913:47.1
HOT-1 yeah, lights are on.
0913:47.8
HOT-2 takeoff check's complete, I'm on the roll. thank you sir."


http://www.airdisaster.com/cvr/aa587.shtml

KLM 4805 (RDO is PanAm, APP is ATC) - if the Controller had given them their route clearance sooner, or just said 'Continue holding' after giving it - or if the pilot hadn't mistaken it for takeoff clearance - or if he'd responded in English instead of Dutch - or if ATC hadn't said 'OK' - or if there hadn't been a screech on the radio - there would have been no accident:-

"1705:44.8 KLM Uh, the KLM ... four eight zero five is now ready for take-off ... uh and we're waiting for our ATC clearance.
1705:53.4 APP KLM eight seven * zero five uh you are cleared to the Papa Beacon climb to and maintain flight level nine zero right turn after take-off proceed with heading zero four zero until intercepting the three two five radial from Las Palmas VOR. (1706:08.2)
1706:09.6 KLM Ah roger, sir, we're cleared to the Papa Beacon flight level nine zero, right turn out zero four zero until intercepting the three two five and we're now (at take-off). (1706:17.9)
ca. 1706:13 KLM-1 We gaan. (We're going)
1706:18.19 APP OK.
1706:19.3 RDO No .. eh.
1706:20.08 APP Stand by for take-off, I will call you.
1706:20.3 RDO And we're still taxiing down the runway, the clipper one seven three six.
1706:19.39 - 1706:23.19 RDO and APP communications caused a shrill noise in KLM cockpit - messages not heard by KLM crew.
1706:25.6 APP
APP Thank you
1706:32.43 KLM-3 Is hij er niet af dan? {Is he not clear then?}
1706:34.1 KLM-1 Wat zeg je? {What do you say?}
1706:34.15 KLM-? Yup.
1706:34.7 KLM-3 Is hij er niet af, die Pan American? {Is he not clear that Pan American?}
1706:35.7 KLM-1 Jawel. {Oh yes. - emphatic}"


http://www.airdisaster.com/cvr/tenetr.shtml

[Edited 2006-11-27 04:44:01]
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
don
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 12:46 pm

In addition to the examples given above, the following accidents are also due to the human factors.

1. Flying tigers B747 Freighter Crash in Kuala Lumpur in 1989 due to crew fatigue and no proper briefing

2. UA 173 running out of fuel in Portland, OR in 1978

3. Western Airlines DC10 crash in Mexico City in 1979 after landing on a wrong RW

The best example for advantages of CRM is the United 232 DC-10 incident in Sioux City, Iowa in 1989.
 
mav75
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:05 pm

Quoting Tg 747-300 (Reply 18):
What about the Western DC-10 wher the crew started experimenting with the engines during cruise..

That was actually National Airlines flight 27 from MIA-SFO on 11/3/1973 .(DC-10-10 N60NA) The fan blades pierced the cabin and a passenger was killed. I think the poor guy was sucked out of the aircraft. They diverted to ABQ.

There was an infamous Western DC-10 crash though. It was flight 2605 (DC-10-10 N903WA) on October 31, 1979 from LAX-MEX. The aircraft mistakenly landed on a runway that was under construction and killed 72 people. IIRC, one of the contributing factors to this crash was a poor dynamic between the Captain and the F/O. The Captain was giving the F/O a hard time (about really stupid stuff) and the F/O basically clammed up and let the Captain crash the plane into construction equipment on the closed runway.
 
phljjs
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:16 pm

Quoting SSTsomeday (Reply 16):
3) I recall AC had a 767 run out of fuel about 20 years ago and glide to a landing on a closed airport runway because of confusion at fueling between kilograms and pounds. It landed at Gimli Industrial Park Airport (which I believe was being used that day for drag racing) under no power, so it was then nicknamed the Gimli Glider. However - I don't think that this can be fairly attributed to "recklessness." Besides, some pretty heroic flying saved the passengers.


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

That was actually Air Transat, not Air Canada. The pilots were hailed as heros, but not trusting the computers and warning signals in the cockpit that pointed out the fuel leak put them that position in the first place. National Geographic featured it on their "Air Emergency" series last year.
 
Tg 747-300
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:22 pm

The G-III accident in Houston back in May or June 2004 also comes to mind.

And also the Chanllenger in Colorado.


tg 747-300
intentionally left blank
 
OPNLguy
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:27 pm

Quoting PHLJJS (Reply 22):
That was actually Air Transat, not Air Canada. The pilots were hailed as heros, but not trusting the computers and warning signals in the cockpit that pointed out the fuel leak put them that position in the first place. National Geographic featured it on their "Air Emergency" series last year.

Actually, he's correct--the 767 at Gimli was Air Canada. The Air Transat was an A330 that dead-sticked into the Azores. Two separate incidents, with Air Transat being the more current of the two.
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
Lucky42
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:27 pm

Quoting Tg 747-300 (Reply 18):
What about the Western Dc-10 wher the crew started experimenting with the engines during cruise

I think you mean National Airlines DC-10 over ABQ crew was determined to have caused #3 eng to overspeed and suffered an uncontained engine failure that caused the separation of a pax window and one of the passengers was ejected from the plane.....
 
NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:27 pm

PHLJJS, I think you're confusing the 'Gimli Glider' with the 'Azores Glider.'

Further, in the latter case, I believe that the instruments warned of a 'fuel imbalance' but weren't designed to warn specifically of overall higher-than-normal fuel consumption. The crew didn't 'twig' either - with the result that the automatic systems pumped all the fuel over to the wing that was losing fuel, and out through the leak.......

http://www.rvs.uni-bielefeld.de/publ...s_and_accidents/airtransat236.html
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
jeffry747
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:29 pm

Wasn't AF358 partially due to the pilots disagreeing whether or not to land the plane?
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LongbowPilot
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:45 pm

Another item that might be of interest for you..

Eventhough the airplanes today have modern marvels that keep the sometimes tired, weary, and cowboyish pilots in check, we find ourselves depending on that technology entirely too much. One can sit on the ground, evaluate the data, read the NTSB findings, and draw conclusions of what the crew did wrong. Just remember objective remarks substantiated by fact is one thing and is always a great way to conduct a discussion.

as long as

you can keep it objective. The second you add adjectives to convey your opinion then you are stepping outside this objective area of discussion and are slandering someone. Then it is no longer a productive debate but a mud throwing war. Just remember as humans with a big task, and job in life we are expected to perform with split second decisions. Simple decisions that can have disastorous results. We are prone to mistakes, and remember that irony is always waiting in the wings to byte you in the arss.

In long, I'm glad that most were objective in this thread and spared the personal feelings. It is rare to see this, because others are not so objective and it gets real ugly.
 
EMBQA
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 1:57 pm

The Delta 727 crash in DFW. The flight crew spent part of the pre-flight BS'ing with a Flight Attendent... forgot to set the slats for take of and crashed killing several
"It's not the size of the dog in the fight, but the size of the fight in the dog"
 
phljjs
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 2:05 pm

Yes, you guys are right. Thanks for correcting me.
 
NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 2:30 pm

No problem, PHLJJS.

One thing I forgot to mention; the primary cause of the 'Azores glider' case was actually bad maintenance, not bad piloting:-

"The investigation revealed that the cause of the accident was a fuel leak in the number two engine, caused by an incorrect part installed in the hydraulics system by Air Transat maintenance staff. The part did not maintain adequate clearance between the hydraulic lines and the fuel line. This allowed vibration in the hydraulic lines to eventually degrade the fuel line, and cause the leak. Air Transat accepted responsibility for the incident and was fined CAN$250,000 by the Canadian government which is still today the largest fine in Canadian history."

http://en.wikipedia.org/wiki/Air_Transat_Flight_236
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
mav75
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 4:19 pm

Quoting LongbowPilot (Reply 28):
In long, I'm glad that most were objective in this thread and spared the personal feelings. It is rare to see this, because others are not so objective and it gets real ugly.

I agree. Here is what happens when you stick to the topic at hand and not go off on half baked, flame baiting tangents. It was nice to participate in a thread where everyone submitted factually correct information and helpful, constructive insights for the benefit of another a.netter. Maybe in the future there can be more threads like this.
 
bill142
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 5:07 pm

What about the Bashkirian Airlines 2937 and DHL 611 collision over germany. It would relate more to the attitudes at Sky Guide more so then the flight decks of the respective airliners.

http://en.wikipedia.org/wiki/Bashkirian_Airlines_Flight_2937
 
peh
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 5:44 pm

Quoting NAV20 (Reply 8):
possible weakening of the rudder structure due to chemical contamination.

This is interesting. I hadn't heard this. What's your source?
Flown: ATR72, DASH 8, 737, 747, 767, 777, A300, A320, A321, A330, A340, MD80
 
BCAL
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 5:51 pm

Rather surprising that nobody has mentioned the crash of BEA’s (British Airways) Hawker Siddeley Trident 1C G-ARPI at Staines, near LHR, on 18 June 1972 whilst operating Flight No BE548 from LHR-BRU. It was the worst disaster involving a Trident, the second worst air crash in the UK, and whilst the cause of the accident is known, it is unknown who retracted the droops that caused the aircraft to fall into a deep stall from which recovery was impossible.

The crash happened at a time when moral amongst the BEA pilots was at a low, with some pilots favouring strike action whilst others were totally against this. In the latter case was Captain Stanley Key who had a massive row with a striking pilot in the pilots’ rest room before taking command of BE548 as a substitute captain. Roistered to fly with Captain Key were two relatively young, inexperienced co-pilots who had witnessed their captain’s bust-up. Flight BE548 took off normally from LHR but within minutes she crashed into the ground killing all 118 occupants on board. The inquiry into the disaster revealed that the Captain had a severe heart problem that had not been detected in his medical check ups, and in all probability his earlier argument with a striking colleague had brought on a heart attack.

Someone on the flight deck of G-ARPI that late afternoon had retracted the droops at 60mph below the safety margin. Was it Captain Key, who obviously was in intense pain with a heart attack coming on, and did the young pilots, having a few minutes earlier witnessed at first hand their captain’s temper, not realise that he had inadvertently retracted the droops or were too scared to tell him (since the co-pilots were still in training and the captain would in normal events be monitoring their performance)? Or was it one of the young pilots, in a state of panic as the captain had already passed out? Matters were further complicated by the fact that an off-duty captain was also present on the flight deck, being ferried to BRU to take command of a BEA Merchantman (Vanguard). The inquiry also revealed that this captain was spraying air freshener in the cockpit at the time of the crash.

The inquiry could not determine which of the pilots pulled the wrong lever, or what happened subsequent to that and before the Trident collided with the ground, as there were no CVRs at that time. CVRs became compulsory in the UK shortly after this accident.
MOL on SRB's latest attack at BA: "It's like a little Chihuahua barking at a dying Labrador. Nobody cares."
 
wunala
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 5:57 pm

have you tried http://www.atsb.gov.au/publications/...nvestigation_reports.aspx?mode=avi


there are several ones that mention crew attitude, and how they were more interested in chatting about last night than arming doors correctly, etc.
 
flyfisher1976
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 7:14 pm

Quoting NAV20 (Reply 8):
possible weakening of the rudder structure due to chemical contamination.



Quoting Peh (Reply 34):
This is interesting. I hadn't heard this. What's your source?

Neither had I...where did you read this?
 
777236ER
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:02 pm

You don't need to look any further than Pinnacle 3701.
Your bone's got a little machine
 
FlyingColours
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:08 pm

There was also the case of the British Midland 737-400 at EMA, The Kegworth Air Disaster. Although the crews attitudes were not really wreckless there was some bad CRM, especially when the cabin crew & passengers heard the pilots announce they had shut down an engine (but the wrong one)...

Quoting BCAL (Reply 35):
The inquiry also revealed that this captain was spraying air freshener in the cockpit at the time of the crash.

Really? I never knew that. Didn't the aircraft after she crashed rest in the field by a busy motorway for a few hours before anyone found it?

I suppose some could also blame the crash of BY226 in Gerona on the crews descision to land at that airfield despite the worsening weather conditions. Although the primary cause has been listed as the failure of the runway lights the crew did choose not to divert but make several approaches to the airport. Even after the aircraft crashed ATC believed they had actually descided to divert - they were alerted to the accident when a passenger walked across into the terminal.

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FlyingColours
Lifes a train racing towards you, now you can either run away or grab a chair & a beer and watch it come - Phil
 
David L
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 9:42 pm

Quoting SSTsomeday (Reply 16):
because of confusion at fueling between kilograms and pounds

Just to be picky, I think the confusion was between kilograms and litres.
 
OPNLguy
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 10:37 pm

Quoting SSTsomeday (Reply 16):
3) I recall AC had a 767 run out of fuel about 20 years ago and glide to a landing on a closed airport runway because of confusion at fueling between kilograms and pounds.



Quoting David L (Reply 40):
Just to be picky, I think the confusion was between kilograms and litres.

From aviation-safety.net:

"They dripped the tanks and the flightcrew calculated the total amount of fuel by using 1.77 pounds/liter as the specific gravity factor. This was the factor written on the refueler's slip and used on all of the other planes in Air Canada's fleet. On the all-metric Boeing 767 however they should have used 0.8 kg/liter of kerosene.

I think SST gets this one...  Wink
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
ChrisI1024
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:07 pm

Black Box might give you some ideas.
 
NZ747
Topic Author
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:33 pm

Thank you all so much for your help. The information provided has been very useful for my crm assignment. I have to illustrate hazardous attitudes with three case studies.

Quoting NAV20 (Reply 8):
any of those three would fit your bill I'd be happy to look out details/links for you.

Hey Nav20, I am very interested in using the KLM/PanAm Tenerife accident as one of my case studies. However, I am finding it hard to identify all the hazardous attitudes involved, apart from the captain not cross checking the takeoff clearance he thought he heard from tower. Could you please help me identify all of them.

Cheers mate

On another note, I have a friend who is doing a similar crm assignment, but they are discussing instances of poor flight Deck communication, and ways of improving interpersonal communication. I have posted this in another thread so it doesn't get mixed up with this one.
http://www1.airliners.net/discussion...eneral_aviation/read.main/3117171/

Once again guys, your help is very much appreciated!
Cheers,
NZ747  

[Edited 2006-11-27 15:35:42]
 
NBGSkyGod
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:44 pm

Another good one was the crash of a NEA F-27 in Hanover, NH. The crew decended lower than the reccomended altitude and struck Moose Mountain, killing 34 of 44 passengers.
Pilots are idots, who at any given moment will attempt to kill themselves or others.
 
David L
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Mon Nov 27, 2006 11:53 pm

Quoting OPNLguy (Reply 41):

Fair enough. I knew it was a conversion between weight and volume that caused the problem, rather than a direct conversion between metric and imperial weight units. Slightly indirectly, it was a pound/kilogram error. D'oh!
 
NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Tue Nov 28, 2006 12:21 am

Quoting Flyfisher1976 (Reply 37):
Quoting NAV20 (Reply 8):
possible weakening of the rudder structure due to chemical contamination.

Quoting Peh (Reply 34):
This is interesting. I hadn't heard this. What's your source?

Neither had I...where did you read this?

It's recent information, guys, which was the subject of an urgent NTSB Safety Recommendation earlier this year.

As briefly as I can put it, NTSB investigated the rudder of a Fedex A300 which had been damaged during maintenance, and found extensive disbonding between the rudder skin and the honeycomb core. This was traced to hydraulic fluid contamination.

"In addition to the damage that occurred during maintenance, the examination found a substantial area of disbonding between the inner skin of the composite rudder surface and the honeycomb core.2 A tap test inspection3 determined that a disbond of approximately 838 mm (33 inches) by 355 mm (14 inches), or 0.3 square meter (3 square feet), existed. Further examination of the disbonded area revealed traces of hydraulic fluid. Hydraulic fluid contamination between the honeycomb core and the fiberglass composite skin can lead to progressive disbonding, which compromises the strength of the rudder. Further tests on the damaged rudder revealed that a rapid propagation of the disbonding damage could occur during flight."

NTSB linked this up to the case of the Air Transat rudder separation earlier this year (which occurred in level flight on autopilot) and reckoned that this too could have been the result of contamination. It further found that the rudder, in parting company, had also strained the attachment lugs of the tailfin itself.

"While at an altitude of 35,000 feet, about 15 miles south of Marathon, Florida, the flight crew heard a loud bang followed by vibrations that lasted a few seconds. The flight returned to Varadero, where it landed uneventfully. Upon landing at Varadero, the crew discovered that most of the airplane’s rudder had separated in flight with only the bottom closing rib and the spar between the rib and the hydraulic actuators remaining. Further examination of the vertical stabilizer determined that its two rearmost attachment lugs were damaged due to the high stresses associated with the rudder failure and separation. These high stresses may have been dangerously close in magnitude to those that caused the in-flight separation of the vertical stabilizer during the November 12, 2001, accident involving American Airlines flight 587."

In a footnote, NTSB also described the symptoms, which seem to me to be remarkably similar to the violent rudder swings which are thought to have caused AA587's rudder and fin to break off:-

"4 When the rudder separation began, the rudder started to flutter, or swing back and forth violently. This, in turn, led to the vertical stabilizer moving left and right and the stress in the lugs increasing to the point where the lugs became delaminated."

The 'good news' is that the contamination was traced to rivets on certain models of A300/310 (and some A330s/A340s) which penetrated both the rudder skin and the core, and provided a path for spilled hydraulic fluid. Apparently the rivets have been 'designed out' since that time, so the danger has been avoided in later models.

"1 Airbus identifies the configuration by which the rudder skin panels were attached to the front spar on some A300s and A310s, including the incident airplane, as premodification 8827. In this configuration, rivets penetrate the rudder’s honeycomb core to join the rudder skin panels to the front spar. This configuration is identified as premodification 40904 when used on A330s or A340s. About 400 A-300 series airplanes were manufactured with the premodification 8827 or 40904 configuration before the rudder skin panel and front spar interface was redesigned. There are no A330s or A340s on the U.S. registry."

Further 'good news' is that, on NTSB advice, the FAA has ordered urgent inspections of all aircraft which could have this problem; with the added advantage that the inspectors will now have a much better idea of what to look for, and exactly where to look. So we can be reasonably sure that the problem will not recur.

Full text of the NTSB's Safety Recommendation here:-

http://www.ntsb.gov/recs/letters/2006/A06_27_28.pdf
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
NAV20
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Tue Nov 28, 2006 12:34 am

Quoting NZ747 (Reply 43):
Hey Nav20, I am very interested in using the KLM/PanAm Tenerife accident as one of my case studies. However, I am finding it hard to identify all the hazardous attitudes involved, apart from the captain not cross checking the takeoff clearance he thought he heard from tower. Could you please help me identify all of them.

NZ747, other factors - probably contributing to the impatience/confusion - included diversions due to a bomb threat, fog, delays, taxiing mixups, etc. Aircraft had to 'backtrack' along the single runway at Teneriffe, and Ground Control appear to have given Panam sloppy instructions as to which taxiway to turn off on. At a guess, the relatively poor view from a taxiing 747 can't have helped either.

Some basic information on here (apologies for the site being lousy with pop-ups):-

http://www.airdisaster.com/cgi-bin/v...F&airline=KLM+Royal+Dutch+Airlines

Full CVR transcript here - takes a bit of deciphering, I'm afraid, but it reflects the taxiing/visibility difficulties etc:-

http://www.airdisaster.com/cvr/tenetr.shtml

I'm sure there is a lot more information if you google - but I hope that gives you a start, anyway!

[Edited 2006-11-27 16:42:19]
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
 
Lemurs
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Tue Nov 28, 2006 7:26 am

Funnily enough, I like reading NTSB reports. I've probably skimmed through a few dozen of the most interesting ones over the last 50 years, and the one I can think of that comes closest to being caused by bad crew attitude is Braniff Flight 352. 1967, L-188 flight from Houston to Dallas.

There was a big thunderstorm in the area, and against the recommendations of ATC, they tried to bypass the storm on the west instead of the east because it was a more direct route. No one had gone in that direction, and ATC was telling them it'd be safer to go east. They ignored the recommendation, went west, hit serious winds, and the plane broke up due to exessive strain when performing an emergency maneuver to get out of severe turbulance.

The reason I say it exhibits bad attitude on the part of the crew is the following quote from the CVR recovered after the accident...I am lifting this from Wikipedia because they've encapsulated it pretty well:

The NTSB correlated the cockpit conversations with the ATC communications transcript and noted that it was the first officer, at the captain's request, who asked ATC about hail in the area and received the response from ATC that "no ... they've all deviated around to the east." At that point, according to the CVR transcript, the captain advised the first officer,

"No, don't talk to him too much. I'm hearing his conversation on this. He's trying to get us to admit (we're makin)a big mistake coming through here."

http://en.wikipedia.org/wiki/Braniff_Flight_352
http://amelia.db.erau.edu/reports/ntsb/aar/AAR69-03.pdf
There are 10 kinds of people in the world; those who understand binary, and those that don't.
 
flyfisher1976
Posts: 777
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RE: Air Crashes Due To Hazardous Crew Attitudes (HELP)

Tue Nov 28, 2006 10:25 am

Quoting NAV20 (Reply 46):
It's recent information, guys,

Sorry to be nit picky...but to suggest:

Quoting NAV20 (Reply 8):
Other contributing causes are thought to have included



Quoting NAV20 (Reply 8):
possible weakening of the rudder structure due to chemical contamination

...is a rather bold statement considering. The NTSB report does not list this as a contributing factor in this accident, nor was the report recently revised to reflect these findings.

Quoting Peh (Reply 34):

This is interesting. I hadn't heard this. What's your source?



Quoting NAV20 (Reply 46):
In a footnote, NTSB also described the symptoms, which seem to me to be remarkably similar to the violent rudder swings which are thought to have caused AA587's rudder and fin to break off:-

Actually the report does not say this at all. The report only compares the stress factors caused by the fluttering to be of similar magnitude to those of AA587 just before the structure separation:

Quoted directly from your source:

"When the rudder separation began, the rudder started to flutter, or swing back and forth violently. This, in turn, led to the vertical stabilizer moving left and right and the stress in the lugs increasing to the point where the lugs became delaminated."

"These high stresses may have been dangerously close in magnitude to those that caused the in-flight separation of the vertical stabilizer during the November 12, 2001, accident involving American Airlines flight 587"

"the flight crew heard a loud bang followed by vibrations that lasted a few seconds."

Sorry to drag this back off topic, but you have severely misinterpreted this report. They are only making this comparison because of the similar stress factors. Nowhere is there any implication that chemical contamination was a contributing factor in AA587 crash.

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