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ANA 737-700 close call on Sept 6 2011

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  • #16
    Originally posted by Gabriel View Post
    Yaw is hard to "feel", especially a slowly increasing yaw as the one you'd have with smooth increasing ammounts of rudder trim.

    Also roll is hard to feel, and roll would not have started until the autopilot could not keep with the yaw-induced roll tendency and gave up, and then bang!
    why would you think it was smooth and increasing? to activate the door unlock, apparently you have to turn and hold in position until the door is opened. why would someone who thought they were unlocking the door turn the knob smoothly and slowly?

    i think you're giving this guy too much credit. furthermore, if he was doing what he was supposed to be doing, i.e., monitoring the instruments, he would have noticed that the aircraft was turning...all by itself and when it wasn't supposed to.

    Comment


    • #17
      Originally posted by TeeVee View Post
      why would you think it was smooth and increasing? to activate the door unlock, apparently you have to turn and hold in position until the door is opened. why would someone who thought they were unlocking the door turn the knob smoothly and slowly?
      I'm not sure about this, but I think that the rudder trim knob is in fact a switch. That is, the rudder trim displacement is not proportional to the knob input. Instead, the rudder trim increases while you hold the knob turned, and stays put when you release it. The knob self centers in the middle (off) position when you are not holding it turned.

      i think you're giving this guy too much credit. furthermore, if he was doing what he was supposed to be doing, i.e., monitoring the instruments, he would have noticed that the aircraft was turning...all by itself and when it wasn't supposed to.
      I intended to reply only to your "this guy should have had a clue when he felt the aircraft starting to yaw and buck a bit", not to the rest of your post about the mistake itself.

      That said, well, yes, I'm more prone to forgive a single instantaneous gross error like this one than an ongoing display of crappy airmanship like AF. Especially when the very same relatively low time FO that failed at such a stupid task like opening a cockpit door was, immediately after that, able to display a great airmanship by recovering a heavily out of trim airplane flying at night from a high altitude, high speed (overspeed in fact), high bank (inverted in fact), very nose-down dive upset, and do it alone while the captain was still stuck out of the cockpit.

      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
      --- Defend what you say with arguments, not by imposing your credentials ---

      Comment


      • #18
        Teevee,

        People make "odd" mistakes all the time.

        Ever seen people put their car keys in the fridge? Ice cream in the microwave?

        It doesn't take much to be distracted. The switch, while different, is not THAT different.

        Your friend might think he's an arse for getting it wrong. I think your friend has a very idealistic view of the world and doens't acknowledge how easy it is to err, or doesn't acknowledge his own errors. We've all make switching mistakes, no matter how careful we are. It is a fact of life. The key is to make them minor ones, and to catch them.

        There have been plenty of incidents from mis-switching... one that stands in my mind was when after takeoff the Captain called for Gear Up, and the F/O selected the flaps to up. Big whoops.


        I also think you don't quite understand how the rudder trim switch, or system, works. Imagine this: The flight deck selector needs you to rotate the switch to the far right, and hold in in that position, until the person opens the door.

        The Rudder trim, if HELD in the SAME position, will slowly run the rudder trim in that direction. You don't need to rotate the selector slowly... the rudder trim runs when it is held in that position. With the autopilot engaged, the plane will not buck and yaw and roll... it will continue flying along its merry way. The clue will be that the control column is slowly rotating to hold the wings level... but if the pilot is watching the door, or the security camera while the person enters the cockpit....

        The first you know about it is when the aileron authority runs out and the aircraft rolls violently.

        I think you'll find most pilots will look at this and think "its an unusual and a bad mistake to make... but I can see how he's done it". And we'll all walk away and have a renewed sense of "there but for the grace of...."

        One positive... at least it sounds like the jet upset was appropriately handled.

        Comment


        • #19
          Could this have happened on an Airbus?

          Comment


          • #20
            Originally posted by MCM View Post
            With the autopilot engaged, the plane will not buck and yaw and roll... it will continue flying along its merry way. The clue will be that the control column is slowly rotating to hold the wings level... but if the pilot is watching the door, or the security camera while the person enters the cockpit....

            The first you know about it is when the autopilot's aileron authority (which is less than the full aileron authority) runs out, the autopilot self-disconnects, the control wheel that the AP was turning self centers, and the aircraft rolls violently.
            Added the underlined parts. Correct me if they are wrong.
            One positive... at least it sounds like the jet upset was appropriately handled.
            To balance the filed a bit (against what I've already said), I agree it's commendable but I bet that the 2.87Gs was not necessary and was more a result of panic (or at least anxiety) than required to straighten it up. Ok, with a smoother pull a bit more of altitude would have been lost but the load factor was beyond the envelope and hence dangerous. On the other hand, I'm sure that he rolled first and pulled up then (the right thing to do, and not the other way around or we would be talking of a completely different accident)

            --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
            --- Defend what you say with arguments, not by imposing your credentials ---

            Comment


            • #21
              Originally posted by Fear_of_Flying View Post
              Could this have happened on an Airbus?
              I think that at least some Airbuses have the rudder trim inhibited while the AP is on.

              --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
              --- Defend what you say with arguments, not by imposing your credentials ---

              Comment


              • #22
                Originally posted by MCM View Post
                Teevee,

                People make "odd" mistakes all the time.

                Ever seen people put their car keys in the fridge? Ice cream in the microwave?

                It doesn't take much to be distracted. The switch, while different, is not THAT different.

                Your friend might think he's an arse for getting it wrong. I think your friend has a very idealistic view of the world and doens't acknowledge how easy it is to err, or doesn't acknowledge his own errors. We've all make switching mistakes, no matter how careful we are. It is a fact of life. The key is to make them minor ones, and to catch them.

                There have been plenty of incidents from mis-switching... one that stands in my mind was when after takeoff the Captain called for Gear Up, and the F/O selected the flaps to up. Big whoops.


                I also think you don't quite understand how the rudder trim switch, or system, works. Imagine this: The flight deck selector needs you to rotate the switch to the far right, and hold in in that position, until the person opens the door.

                The Rudder trim, if HELD in the SAME position, will slowly run the rudder trim in that direction. You don't need to rotate the selector slowly... the rudder trim runs when it is held in that position. With the autopilot engaged, the plane will not buck and yaw and roll... it will continue flying along its merry way. The clue will be that the control column is slowly rotating to hold the wings level... but if the pilot is watching the door, or the security camera while the person enters the cockpit....

                The first you know about it is when the aileron authority runs out and the aircraft rolls violently.

                I think you'll find most pilots will look at this and think "its an unusual and a bad mistake to make... but I can see how he's done it". And we'll all walk away and have a renewed sense of "there but for the grace of...."

                One positive... at least it sounds like the jet upset was appropriately handled.
                talk about total loss of situational awareness...i may put my keys in the fridge, but 175 lives are not dependent on where i put my keys. also, without any question whatsoever, placing keys in the fridge is a direct result of not paying attention and being distracted.

                my friend was telling me that as part of her training, she was placed in a blacked out sim and was required to identify all of the controls. not sure if this is standard, but just from the looks of these two knobs, the guy should've known he was twisting the wrong one.

                Comment


                • #23
                  Originally posted by Fear_of_Flying View Post
                  Could this have happened on an Airbus?
                  No.

                  Comment


                  • #24
                    Originally posted by TeeVee View Post
                    my friend was telling me that as part of her training, she was placed in a blacked out sim and was required to identify all of the controls.
                    Who is she working for.....Ninja Airlines?

                    Tell your friend to be a little less critical of her fellow pilots and simply use this incident as teaching point. As MCM said, I don't know of a pilot who doesn't look at this and hope they wouldn't make a similar mistake, but they realize they probably have....just the results weren't as spectacular.

                    You're telling me that none of you have ever gone to use your power windows in the car and found yourself hitting the door unlock button instead. Or you go to use the turn signal and suddenly the windshleld wipers go on? Well there's far more 'buttons' in a cockpit and most times when you hit the wrong one nothing bad happens.....this guy just picked the wrong button with more surprising results.

                    While I metioned that we can all use this a a teaching point to pay closer attention, there are also cockpit design issues, and this is just poor placement.
                    Last edited by Vnav; 2011-10-01, 03:41.
                    Parlour Talker Extraordinaire

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                    • #25
                      Originally posted by Vnav View Post
                      Who is she working for.....Ninja Airlines?

                      Tell your friend to be a little less critical of her fellow pilots and simply use this incident as teaching point. As MCM said, I don't know of a pilot who doesn't look at this and hope they wouldn't make a similar mistake, but they realize they probably have....just the results weren't as spectacular.

                      You're telling me that none of you have ever gone to use your power windows in the car and found yourself hitting the door unlock button instead. Or you go to use the turn signal and suddenly the windshleld wipers go on? Well there's far more 'buttons' in a cockpit and most times when you hit the wrong one nothing bad happens.....this guy just picked the wrong button with more surprising results.

                      While I metioned that we can all use this a a teaching point to pay closer attention, there are also cockpit design issues, and this is just poor placement.
                      Come on! Next thing you'll tell me that a pilot would turn off the hydraulics system instead of the engine anti ice? Geezzzz...

                      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                      --- Defend what you say with arguments, not by imposing your credentials ---

                      Comment


                      • #26
                        Originally posted by TeeVee View Post
                        i may put my keys in the fridge, but 175 lives are not dependent on where i put my keys.
                        Because if they were then you'd be immune to putting your keys in the fridge?

                        --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                        --- Defend what you say with arguments, not by imposing your credentials ---

                        Comment


                        • #27
                          Originally posted by Gabriel View Post
                          Come on! Next thing you'll tell me that a pilot would turn off the hydraulics system instead of the engine anti ice? Geezzzz...
                          Gabriel,

                          So you liked that story, huh? I'd like to think that I'd never make that particular mistake....and I'd really like to think that I'd figure it out before I got too far in the checklist, but you never know. For most pilots in modern jet aircraft, the things they touch the most are the FMS and the Autoflight Mode Control Panel. I can't tell you how many times I've gotten some reroute in flight and hit the execute button on the FMS only to see that I've just sent the magenta line off to some God unknown place. I've defintiely reached up to the MCP and hit the wrong button only to say "whoops, didn't want to do that!" (hell, half the backlighting on the buttons never works in the dark).

                          Unfortunately, there's more where that came from. Our Safety dept. does a good job of publishing the data from our ASAP and FOQA programs in newsletters to make us aware of potential pitfalls...and you quickly realize that these things are happening to the pilots that you fly with.....very professional and intelligent folks, and if it can happen to them, you'd be a fool to think it can't happen to you.

                          That's why I'm amazed at the folks here who've never even sat in the pointy end of a jet who can't even imagine how this would happen. I think they really believe that all pilots on 6 hour flights sit staring intently at the instruments, their hands poised to instantly take over the controls at any second.....it sounds good in theory, but it just ain't so. People make mistakes, and last time I checked, Pilots were people (well, I'm closer to a demi-god, but most pilots are mortals) If you've made silly mistakes in your car, you can make them in a plane as well.
                          Parlour Talker Extraordinaire

                          Comment


                          • #28
                            Originally posted by Vnav View Post
                            That's why I'm amazed at the folks here who've never even sat in the pointy end of a jet who can't even imagine how this would happen. I think they really believe that all pilots on 6 hour flights sit staring intently at the instruments, their hands poised to instantly take over the controls at any second.....it sounds good in theory, but it just ain't so. People make mistakes, and last time I checked, Pilots were people (well, I'm closer to a demi-god, but most pilots are mortals) If you've made silly mistakes in your car, you can make them in a plane as well.
                            What amazes me is that the people who put the switch there can't imagine how this would happen. That is quite amazing.

                            It's too bad we can't design some sort of computerized flight control system that would use a sort of "law" to limit the amount of bank angle a pilot could command...

                            Comment


                            • #29
                              Originally posted by Gabriel View Post
                              Because if they were then you'd be immune to putting your keys in the fridge?
                              immune? no. but i wouldn't do it. period. in 14 years of having people's lives in my hands, i never made a mistake out of lack of concentration or being distracted. how? i paid attention to the task at hand. sure, i had less things to monitor and not as many switches and buttons to play with. so yeah, not quite the best comparison.

                              bottom line here is that this guy completely lost situational awareness as so many of you are so fond of saying.

                              and if you read my half-joking post from earlier on, you'll note that i criticize boeing for the design of the knob as well. totally stupid design given its placement.

                              Comment


                              • #30
                                Originally posted by Vnav View Post
                                Who is she working for.....Ninja Airlines?

                                Tell your friend to be a little less critical of her fellow pilots and simply use this incident as teaching point. As MCM said, I don't know of a pilot who doesn't look at this and hope they wouldn't make a similar mistake, but they realize they probably have....just the results weren't as spectacular.

                                You're telling me that none of you have ever gone to use your power windows in the car and found yourself hitting the door unlock button instead. Or you go to use the turn signal and suddenly the windshleld wipers go on? Well there's far more 'buttons' in a cockpit and most times when you hit the wrong one nothing bad happens.....this guy just picked the wrong button with more surprising results.

                                While I metioned that we can all use this a a teaching point to pay closer attention, there are also cockpit design issues, and this is just poor placement.
                                she was trained by the US Navy, where she qualified in helos and some transport aircraft...not sure which. after her active duty enlistment she qualified on the 737 and has flown it commercially for over 10 years.

                                and i won't tell her to be less critical of anything. she is, admittedly, a perfectionist. one of her check pilots commented that she is a bit too thorough. not sure if that even makes sense, but i'm not surprised.

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