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How to crash a 737 using your solid stick and rudder skills

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  • How to crash a 737 using your solid stick and rudder skills

    My findings:
    • Captain: (58, ATPL, 10,158 hours total, 2,027 hours on 737-200, 82 hours on 737-236A subtype) was pilot flying.
    • Did not pull up relentlessly, pushed over in fact to recover.
    • Ignored QRH procedures and had no proper training on type.
    • failed to understand the key differences between a -200 and a -236A.
    • Probably thought his basic airmanship alone was sufficient.
    • And that procedures are for those 'magenta line' children.
    • Is dead.
    • Along with 126 pax and crew.


    The captain made control inputs obviously in an attempt to recover out of the critical situation, but neither pilot applied the FCOM/QRH procedures.
    "...critical violation of procedures was observed with regard to implementation and conformance of QRH, FCOM and Ops Manual recommended actions / instructions.
    ...non- adherence to Boeing recommended QRH and FCOM remedial actions / procedures due to non-availability of customized aircraft documents (at Bhoja Air) for Boeing 737-236A (advanced version of Boeing 737-200 series) contributed towards the causation of accident.
    It's all here: http://avherald.com/h?article=44e48c2a/0000&opt=0

  • #2
    Originally posted by The article
    there was no control wheel activity recorded for approximately 6 seconds and no control column activity for approximately 8 seconds. The cockpit crew was probably in a state of confusion and unsure of remedial actions to be taken to get out of unsafe set of conditions, as the aircraft was still observed flying with auto-throttle in engaged mode."
    Cowboy stick and rudder flying? I'm sorry, I do not recall being taught to make no control inputs while on an two-dot-off-ILS very close to the ground while I'm confused over automation.

    Instead, I believe the broad fundamental thing to do is fly the plane and go around- of which they did neither.

    Sorry Evan, this gets an F.

    This is a crew overwhelmed by what the automation should be doing and who paid no attention to fundamentals. Not an example of someone ignoring procedure, it's an example of someone ignoring fundamentals.

    Try again.

    And let's be clear here, automation and procedures are all ok. But I just hope that someday you will understand that there's a certain tension:

    There's evidence that as you study more and more and more procedures that you forget some things, and it seems that some folks forget the basics.

    Procedures and memory checklists are great, but when these procedures and checklists are devoid of basics that's when I start going . And when we see crews who act as though they are devoid of basics and people die, I (and someone else I know) spew parlour talk on obscure avaition fora. Then we have you who sees that the FCOMQRH200236A, item 2C is violated, but do not see the basic flaw of not flying the plane when you are on the final stages of an ILS and getting your butt kicked by a thunderstorm that Boeing Bobby's basic, wide-reaching rule, is that you don't enter it.

    The approach is going to hell...fly the plane and go around. I don't care if it's a 200, 236A or a 172 or what the QRHFOCMPOH says.
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

    Comment


    • #3
      Damn... I have 0 hours in type or in fact anything larger than a 172 but I still know:

      1) Attempting to fly through thunderstorm = bad
      2) Attempting to get the autopilot to fly through a thunderstorm for you = worse
      Be alert! America needs more lerts.

      Eric Law

      Comment


      • #4
        the aircraft was at 1900 feet AGL at that point, 4 seconds later the aircraft was at 900 feet AGL with the pitch increasing from 6 to 12 degrees nose up. The GPS alert "Windshear! Windshear" sounded. Autothrottle and Autopilot continued, no remedial action was taken by the crew.
        Encounter a wind shear, loose 1000 feet in 4 seconds (that'd be about a 15,000 fpm descent) and you are less than 1000 ft AGL and you sit there and do nothing?

        I don't recall reading that procedure anywhere, nor hearing it from a 172 Flight Instructor...

        You ever hear anything like that Elaw?

        Is that what you do for Tomahawks, Gabriel?

        Is it something to do with the procedural differences in a 737-200 versus a -236A?
        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

        Comment


        • #5
          If the report is to be believed, the carrier in question is a major case of that which rhymes with mustardluck. Old, decrepit equipment, a training program that dreams of one day being merely inadequate, etc...

          Comment


          • #6
            From my 18hrs stick time in a Piper Cherokee 140 even I know that its "Click Click.....Click Click......manual full power and go around"

            ...basically speaking that is. I'm sure there's some technicalities that go with it but heeeey, let's get our arses further above the ground first.
            If it 'ain't broken........ Don't try to mend it !

            Comment


            • #7
              Originally posted by 3WE View Post
              Encounter a wind shear, loose 1000 feet in 4 seconds (that'd be about a 15,000 fpm descent) and you are less than 1000 ft AGL and you sit there and do nothing?

              I don't recall reading that procedure anywhere, nor hearing it from a 172 Flight Instructor...

              You ever hear anything like that Elaw?
              Nope!

              Originally posted by 3WE View Post
              Is it something to do with the procedural differences in a 737-200 versus a -236A?
              I don't think so:
              737-200 procedure: Don't fly the airplane into the ground.
              737-236A procedure: Don't fly the airplane into the ground.

              This reminds me a little of one of those "things children say" features I read a while back. The child was asked "what should you do if your clothes are on fire?" and the response was "wear different clothes".

              The answer to the question "what should you do if there are thunderstorms where you are flying?" is "fly elsewhere".
              Be alert! America needs more lerts.

              Eric Law

              Comment


              • #8
                Originally posted by brianw999 View Post
                From my 18hrs stick time in a Piper Cherokee 140 even I know that its "Click Click.....Click Click......manual full power and go around"

                ...basically speaking that is. I'm sure there's some technicalities that go with it but heeeey, let's get our arses further above the ground first.
                Brian,

                There was a thread already open for his accident, and yesterday I posted an update with the final report and some comment (notoriously contrary to Evan's comments that these pilots used airmanship).

                I suggest to merge the two threads.

                --- 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


                • #9
                  Originally posted by brianw999 View Post
                  From my 18hrs stick time in a Piper Cherokee 140 even I know that its "Click Click.....Click Click......manual full power and go around"
                  Well, THAT would have been airmanship. Not sitting there watching the AP lose the fight with mother nature, and when it quits and disconnects, sitting there watching Newton fly the plane.

                  --- 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


                  • #10
                    Originally posted by Gabriel View Post
                    I suggest to merge the two threads.
                    I do not second the motion.

                    This is going to be one of those filosofical beauties that may detract from the actual discussion of the incident in question.
                    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                    Comment


                    • #11
                      And yet, an old stick and rudder man with 10,000+ hours on a very non-computerized flight control aircraft became distracted and confused enough to fly this plane into the ground. Partially because he was unfamiliar with the autoflight behaviors of this particular type.

                      I'm not saying good judgement was involved. I'm aware that cockpit gradient and get-there-itis are the primary cause. I'm saying that both of these things are fairly common in crash scenarios.

                      I'm also saying (along with the CAA) that if these pilots and given over to QRH and/or memorized procedures for the type they were flying, everyone would still be alive.

                      What a lot of you are saying is that basic airmanship plus sound judgment would achieve the same result.

                      What you are not acknowledging is the FACT that sound judgement is often clouded or removed by the two aforementioned phenomena and these crashes, which would have been avoided by proper CRM and procedure, continue to happen again and again and again.

                      Basic airmanship goes without saying, but procedural discipline continues to be of questionable importance here. Why? Avaition safety on every flight on every day depends upon 100% fullfillment of training requirements and solid procedural CRM discipline.

                      That's a fact.

                      This is not happening.

                      That is also a fact.

                      Comment


                      • #12
                        Originally posted by Not Evan View Post
                        Procedural discipline goes without saying, but basic airmanship discipline continues to be of questionable importance to Evan. Why? Avaition safety on every flight on every day depends upon good airmanship as well as procedural discipline.

                        That's a fact.

                        This is not happening.

                        That is also a fact.
                        The title of this thread, you basically mean it as written, right?
                        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                        Comment


                        • #13
                          Originally posted by 3WE View Post
                          The title of this thread, you basically mean it as written, right?
                          Yes, I mean how to crash a 737 with your seasoned manual flight skills combined with flawed judgment. That old song and dance. 3WE, the reason procedures are so damned necessary is the flawed judgment part, which seems to effect some very well-seasoned pilots who, if they survive, shake their heads in disbelief. You scoff at procedures but all of your arguments against them assume sound judgment under extreme stress and that is just not how it plays out in these crash scenarios (it only goes that way in all the averted disasters, many of which we never hear about). If every pilot was reliably following well-rehearsed procedures many of these crashes would never have happened. One of the reasons for this is that the procedures are simply telling the crew to do what sound judgment and flawless airmanship would also tell them to do.

                          For instance, in windshear, my 737 QRH (procedure might be different from the -200A) includes immediate TO/GA thrust followed by autothrust disconnect. This very experienced pilot did neither of these things. So he had 40% N1 when he needed 105%. The autothrust reacted to negative pitch by pulling back on power. What he did do was get the nose down on stickshaker, which we know is typically the thing to do but in windshear you want to keep as much pitch as possible (just below stickshaker). My Boeing QRH from 2005 even suggests flying at intermittent stickshaker if ground proximity is a factor. Of course, this assumes you have maximum thrust at work (see beginning of this paragraph).

                          The -200A QRH procedure for windshear is not complex and must be done from memory (no, you don't look it up by number). This crew had never seen it, let alone practiced it. If they had, the F/O, who obviously was thinking clearly, could have simply called out the procedure to get around the gradient issue (another reason we need these things). "Windshear" "TOGA" "Autothrottle off" "Maintain climb attitude" or whatever it is...

                          It's called CRM. It's part of a safety culture.

                          Comment


                          • #14
                            Originally posted by 3WE
                            Originally Posted by Not Evan
                            Procedural discipline goes without saying, but basic airmanship discipline continues to be of questionable importance to Evan.
                            Originally posted by Evan
                            Basic airmanship goes without saying.
                            Sometimes there's just no point in trying.

                            Comment


                            • #15
                              Just for the record, excerpts of a discussion that took place somewhere else in some obscure internet forum regarding the same accident than in this thread.

                              Quizz: Who is "User 1"?

                              Originally posted by User 1

                              I think the procedure must be to manage AoA and pilots must be well-trained to understand what that means and how best to do it in a variety of situations. I think the procedure should just read: "Manage AoA. Smoothly add thrust". If the pilot needs more instruction then that, send them back to school.
                              Originally posted by User 2
                              Manage AoA" is, for me, way too ambiguous. Why don't we replace the full FCOM with a simple "Fly the plane" sentence? If they can't then send them back to school.
                              We already had an "adjust pitch as necessary" stall recovery procedure. It didn't work.

                              The premise is very simple:

                              1- The stall warnings must be silenced (read "The AoA must be reduced at least as necessary to silence the stall warnings").

                              Within that premise, you can pull up all you want. If, in the process, the stall warning starts again, then return to 1-. And there you have the "intermittent stickshaker".
                              Originally posted by User 1

                              Too ambiguous for you? Ha, I don't believe that for a second. I just want all pilots to know what you know, rather than a black and white procedure where a grey area might exist. I'm just concerned that procedure + shock factor tend to = overcontrol (i.e. I must push the nose over), whereas an instinctive understanding of what is actually happening is much more useful (i.e. I am approaching critical AoA so I must not increase the pitch and should reduce the pitch slightly while adding power if I have any altitude to give).

                              Pilots MUST be trained to understand what "manage AoA" means. They must understand that, at stickshaker you CANNOT raise the pitch, and that you need to reduce it to the extent that this is possible without damaging trees or other aircraft. I objected to the new procedures as being some kind of superficial 'fix' to a problem that needs to be fixed. The problem is that pilots do not universally understand how to manage AoA. Industries have a tendency to make some easy gesture (revising a written procedure) rather than taking a difficult and expensive measure (expanding and supplementing flight training). I don't want them to get away with that. Until all commercial pilots are required to get a first-class education in aerodynamics, and practiced skills for upset situations, I don't feel safe. They can't deal with the grey area without this.

                              I prefer the instinct to arrest pitch and think for a split-second over what terrain or traffic issues are involved. Most of the stall-related crashes we have discussed are due to the pilot either pulling up or doing nothing to reduce AoA for an extended period. Stickshaker is a warning ahead of the event, so I assume there is usually a moment available to assess the circumstances. As I said, it's grey area (play it by the circumstances). No pilot who understands the relationship between AoA and stall is going to pull up, slam on the power or do nothing at all.

                              --- 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

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