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TransAsia Airways plane crashes in Taiwan


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Feb 6th 2015 Taiwan's ASC reported that the investigation so far determined from flight data and cockpit voice recorders: the aircraft received takeoff clearance at 10:51Z, in the initial climb the aircraft was handed off to departure at 10:52:33Z. At 10:52:38Z at about 1200 feet MSL, 37 seconds after becoming airborne, a master warning activated related to the failure of the right hand engine, at 10:52:43Z the left hand engine was throttled back and at 10:53:00Z the crew began to discuss engine #1 had stalled. At 10:53:06Z the right hand engine (engine #2) auto-feathered. At 10:53:12Z a first stall warning occured and ceased at 10:53:18Z. At 10:53:19Z the crew discussed that engine #1 had already feathered, the fuel supply had already been cut to the engine and decided to attempt a restart of engine #1. Two seconds later another stall warning activated. At 10:53:34Z the crew radioed "Mayday! Mayday! Engine flame out!", multiple attempts to restart the engines followed to no avail. At 10:54:34Z a second master warning activated, 0.4 seconds later both recorders stopped recording.

 

Exactly my point, like the BMI crash, pilot error, shut down the wrong engine. 

 

I'm sorry but from what I've read from your quote, it looks more like engines stalling and getting on fire. Maybe I'm wrong, but that's how it looks like to me after reading it.

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As a commercial airline pilot, I always hate to see crashes at all, especially resulting from pilot error. It's miraculous that people survived this incident and I feel for the families of those that did not, but frankly, an engine failure on takeoff is something commercial airline pilots train for repeatedly and should be a completely manageable and recoverable incident.

 

When I first saw the video, my personal opinion based on my training and experience is that they experienced an engine failure followed by an improper reaction from the crew that led to a loss of control. In a multi engine airplane, there is a speed designated Vmc (Velocity, Minimum Control) that is the airspeed at which, with an engine inoperative, it is not possible to control the airplane. Losing an engine during takeoff and climb is the single highest risk point of any flight in a multi engine airplane because the aircraft is already at low speed (close to Vmc) with high power (causes the aircraft to roll towards the dead engine).

 

After reviewing the data that has been made public from the Flight Data Recorder, this accident appears to be even more related to pilot error and their improper reaction to an engine failure. The first step after recognizing an engine failure is to advance BOTH throttles to maximum. You do not, under any circumstances, react by reducing power. The FDR seems to indicate that the right hand engine failed, and the crew reacted by not only reducing power (HUGE MISTAKE and completely AGAINST PROCEDURE) but they also reduced power on the left engine that was still operating and treated it as the failed engine, shutting it down, closing the fuel valves, and manually feathering the engine, effectively making the situation unrecoverable.

 

When we refer to a propeller being "feathered", what it means is that the blades of the propeller actually rotate in their housing to be parallel with the wind. This stops the propeller from rotating, which significantly reduces the drag on that side of the airplane and makes the airplane much easier to control. The aircraft in this accident was equipped with an auto-feather system, and the FDR shows that the right engine failed and was auto-feathered as it was supposed to be. However, the crew reacted by manually shutting down and feathering the left engine.

 

The crew appears to have created a dual engine failure and doomed this airplane, based on the FDR data.

 

As for "what's going on with the Asian airlines", that's a much longer story but basically, from my experience it's a culture problem. I've flown airplanes since I was 15 years old, half of my life at this point. I've flown with a lot of different people from all over the world. I've taught students from all over the world.

 

Based on my experience with foreign pilots, the problem is in their culture. For example, Asian pilots are notorious for their focus on rote memorization of manuals. I could ask any of my students what the manual says on page 127 and they could quote me the entire page, when I asked them what any of that meant or how to practically apply that information, many of them couldn't do so. Most of the Asian student's I taught had a hard time doing anything outside a normal procedure that was established in a book and could be executed through rote memorization alone. They had little to no correlation skills and if anything abnormal happened, they didn't know how to react.

 

A larger problem with a lot of countries as far as commercial aviation goes relates to their Crew Resource Management training, and again, their culture. Here in the US for example, we have completely changed our CRM practices and culture in the last few decades. Gone are the days where the Captain was considered to be "god" with the final authority and decision making skills beyond reproach. Today, we are not a Captain and a First Officer, we are a crew that must work together and with each other at all times, including with the flight attendants, air traffic controllers, company maintenance personnel, dispatchers, and everyone else that could be a valuable resource for us in an emergency. We have accepted the inevitability of human error, and minimize the risk by ensuring that we both do everything in a standardized way, communicate effectively about everything we are doing no matter how small it may seem, and attempt to ensure that we both have a "shared mental model" about what we are doing and why we are doing it. The chances that both of us will make the same mistake at the same time are nearly impossible, and if one of us does make a mistake, the other one points it out.

 

However, many other countries still have deep roots in a "patriarchal" type system, where the Captain is god and is not to be questioned, even if he's doing something wrong; you do not dare challenge him. Communication is also a problem in some countries, where each pilot is just doing their own thing and not communicating it to the other pilot. This type of culture in many countries extends beyond a professional setting, where children are taught growing up that you do not question or disrespect your father, do not challenge authority, do not bring shame upon your family, etc.

 

One need only look as far as the Tenerife Airport Disaster or more recently, the Air Asia crash to see how profound of an effect bad CRM and authority culture can have.

 

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

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I really like that! That God complex that some captains have has caused a countless amount of crashes. Myself, I would check and recheck the captains procedures, they're human, and sometimes I think  the routine of it all leads to complacency. Just like I would want the pilot monitoring to double check all the things I do. Modesty can get you far I'd say. Its really tragic because the captains mistake costs all of their lives, there was an accident around my nearest airport back in 1999, where the instrument failure (ADI) mislead the captain, however the first officer did nothing to challenge the captain, despite the fact he was steering it into the ground. 4 dead because "the captain knows it all"

 

I never considered that as a possible cause, I've always thought it would be inexperience or poor training which lead them to make fatal mistakes. 

Thanks for rectifying

As a commercial airline pilot, I always hate to see crashes at all, especially resulting from pilot error. It's miraculous that people survived this incident and I feel for the families of those that did not, but frankly, an engine failure on takeoff is something commercial airline pilots train for repeatedly and should be a completely manageable and recoverable incident.

 

When I first saw the video, my personal opinion based on my training and experience is that they experienced an engine failure followed by an improper reaction from the crew that led to a loss of control. In a multi engine airplane, there is a speed designated Vmc (Velocity, Minimum Control) that is the airspeed at which, with an engine inoperative, it is not possible to control the airplane. Losing an engine during takeoff and climb is the single highest risk point of any flight in a multi engine airplane because the aircraft is already at low speed (close to Vmc) with high power (causes the aircraft to roll towards the dead engine).

 

After reviewing the data that has been made public from the Flight Data Recorder, this accident appears to be even more related to pilot error and their improper reaction to an engine failure. The first step after recognizing an engine failure is to advance BOTH throttles to maximum. You do not, under any circumstances, react by reducing power. The FDR seems to indicate that the right hand engine failed, and the crew reacted by not only reducing power (HUGE MISTAKE and completely AGAINST PROCEDURE) but they also reduced power on the left engine that was still operating and treated it as the failed engine, shutting it down, closing the fuel valves, and manually feathering the engine, effectively making the situation unrecoverable.

 

When we refer to a propeller being "feathered", what it means is that the blades of the propeller actually rotate in their housing to be parallel with the wind. This stops the propeller from rotating, which significantly reduces the drag on that side of the airplane and makes the airplane much easier to control. The aircraft in this accident was equipped with an auto-feather system, and the FDR shows that the right engine failed and was auto-feathered as it was supposed to be. However, the crew reacted by manually shutting down and feathering the left engine.

 

The crew appears to have created a dual engine failure and doomed this airplane, based on the FDR data.

 

As for "what's going on with the Asian airlines", that's a much longer story but basically, from my experience it's a culture problem. I've flown airplanes since I was 15 years old, half of my life at this point. I've flown with a lot of different people from all over the world. I've taught students from all over the world.

 

Based on my experience with foreign pilots, the problem is in their culture. For example, Asian pilots are notorious for their focus on rote memorization of manuals. I could ask any of my students what the manual says on page 127 and they could quote me the entire page, when I asked them what any of that meant or how to practically apply that information, many of them couldn't do so. Most of the Asian student's I taught had a hard time doing anything outside a normal procedure that was established in a book and could be executed through rote memorization alone. They had little to no correlation skills and if anything abnormal happened, they didn't know how to react.

 

A larger problem with a lot of countries as far as commercial aviation goes relates to their Crew Resource Management training, and again, their culture. Here in the US for example, we have completely changed our CRM practices and culture in the last few decades. Gone are the days where the Captain was considered to be "god" with the final authority and decision making skills beyond reproach. Today, we are not a Captain and a First Officer, we are a crew that must work together and with each other at all times, including with the flight attendants, air traffic controllers, company maintenance personnel, dispatchers, and everyone else that could be a valuable resource for us in an emergency. We have accepted the inevitability of human error, and minimize the risk by ensuring that we both do everything in a standardized way, communicate effectively about everything we are doing no matter how small it may seem, and attempt to ensure that we both have a "shared mental model" about what we are doing and why we are doing it. The chances that both of us will make the same mistake at the same time are nearly impossible, and if one of us does make a mistake, the other one points it out.

 

However, many other countries still have deep roots in a "patriarchal" type system, where the Captain is god and is not to be questioned, even if he's doing something wrong; you do not dare challenge him. Communication is also a problem in some countries, where each pilot is just doing their own thing and not communicating it to the other pilot. This type of culture in many countries extends beyond a professional setting, where children are taught growing up that you do not question or disrespect your father, do not challenge authority, do not bring shame upon your family, etc.

 

One need only look as far as the Tenerife Airport Disaster or more recently, the Air Asia crash to see how profound of an effect bad CRM and authority culture can have.

 

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

 

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Feb 6th 2015 Taiwan's ASC reported that the investigation so far determined from flight data and cockpit voice recorders: the aircraft received takeoff clearance at 10:51Z, in the initial climb the aircraft was handed off to departure at 10:52:33Z. At 10:52:38Z at about 1200 feet MSL, 37 seconds after becoming airborne, a master warning activated related to the failure of the right hand engine, at 10:52:43Z the left hand engine was throttled back and at 10:53:00Z the crew began to discuss engine #1 had stalled. At 10:53:06Z the right hand engine (engine #2) auto-feathered. At 10:53:12Z a first stall warning occured and ceased at 10:53:18Z. At 10:53:19Z the crew discussed that engine #1 had already feathered, the fuel supply had already been cut to the engine and decided to attempt a restart of engine #1. Two seconds later another stall warning activated. At 10:53:34Z the crew radioed "Mayday! Mayday! Engine flame out!", multiple attempts to restart the engines followed to no avail. At 10:54:34Z a second master warning activated, 0.4 seconds later both recorders stopped recording.

 

Exactly my point, like the BMI crash, pilot error, shut down the wrong engine. 

Are you referring to the B737 that crashed short of the runway and just missed the motorway?

They had mixed up the  737 model. Each model has a slightly different cockpit layout/design.

 

So could this be the same issue? 

I'm sorry but from what I've read from your quote, it looks more like engines stalling and getting on fire. Maybe I'm wrong, but that's how it looks like to me after reading it.

 

Where does it say anything about "getting on fire" and such?

Nothing references about fire.

 

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The layout of the 737-4 was more modern than the previous 737-2. It had glass computer displays as opposed to gauges (displaying information about the engines), the fault came from Boeing really, because it was very small which made it hard to read at a quick glance. The BMI pilots misinterpreted it and switched off the wrong engine, and whilst it was pilot error, I think the AAIB did acknowledge the fault in the layout of the instrument, which it recommended for Boeing to fix.

With this Transair it may be the same thing, they may have misinterpreted the instrument leading them to switch off the wrong engine, in the panic of it all.

Edited by SeaHawk14
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The layout of the 737-4 was more modern than the previous 737-2. It had glass computer displays as opposed to gauges (displaying information about the engines), the fault came from Boeing really, because it was very small which made it hard to read at a quick glance. The BMI pilots misinterpreted it and switched off the wrong engine, and whilst it was pilot error, I think the AAIB did acknowledge the fault in the layout of the instrument, which it recommended for Boeing to fix.

With this Transair it may be the same thing, they may have misinterpreted the instrument leading them to switch off the wrong engine, in the panic of it all.

 

Also the engine controls were not in line with the position of the engines. The left engine lever controlled the right engine etc... 

 

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The layout of the 737-4 was more modern than the previous 737-2. It had glass computer displays as opposed to gauges (displaying information about the engines), the fault came from Boeing really, because it was very small which made it hard to read at a quick glance. The BMI pilots misinterpreted it and switched off the wrong engine, and whilst it was pilot error, I think the AAIB did acknowledge the fault in the layout of the instrument, which it recommended for Boeing to fix.

With this Transair it may be the same thing, they may have misinterpreted the instrument leading them to switch off the wrong engine, in the panic of it all.

 

Are you talking about British Midlands flight 92? The crew didn't misinterpret the instrument readings they disregarded the vibration indicators because in the earlier models of the 737 (which the pilots were used to flying) the vibration indicators were unreliable. The crew didn't realize that the newer 737 they were flying gave accurate readings so they ignored it. They were also used to the earlier 737s where the air conditioning packs were fed by the right engine but in the newer 737s both engines fed the air conditioning. So when the crew smelled smoke they assumed that the number 2 engine (right) was the one malfunctioning because they thought it was the only engine feeding the packs when in reality it was the number 1 engine that was malfunctioning which caused them to shut down their only working engine and by the time they had realized their mistake it was too late to restart the number 2 engine.

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Are you talking about British Midlands flight 92? The crew didn't misinterpret the instrument readings they disregarded the vibration indicators because in the earlier models of the 737 (which the pilots were used to flying) the vibration indicators were unreliable. The crew didn't realize that the newer 737 they were flying gave accurate readings so they ignored it. They were also used to the earlier 737s where the air conditioning packs were fed by the right engine but in the newer 737s both engines fed the air conditioning. So when the crew smelled smoke they assumed that the number 2 engine (right) was the one malfunctioning because they thought it was the only engine feeding the packs when in reality it was the number 1 engine that was malfunctioning which caused them to shut down their only working engine and by the time they had realized their mistake it was too late to restart the number 2 engine.

 

Oh? I'm sorry, I didn't remember it correctly then. I haven't read the report in such a long time. Apologies, I thought that they misinterpreted the instrumentation, causing them to switch off the engine. I forgot all about the AVM's & the air conditioning packs. Thanks for rectifying 

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Oh? I'm sorry, I didn't remember it correctly then. I haven't read the report in such a long time. Apologies, I thought that they misinterpreted the instrumentation, causing them to switch off the engine. I forgot all about the AVM's & the air conditioning packs. Thanks for rectifying 

 

Only reason I can recall it so well is because I happened to be reading something about it like a month ago, lol.

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