I wouldn't be so quick to blame ATC (Ground Control) tbh. From what I can tell so far, the coast guard plane was either on, or going on to the runway as the JAL was landing. There are a number of possibilities
JAL didn't have clearance to land but thought they did
Ground Control cleared the coast guard to enter the runway
Ground Control cleared them to enter the runway but their departure was delayed thus JAL should've gone around - if they were told to go around, it might have been too late for the engines to spool up enough power to avoid the other plane.
Ground Control didn't clear them to enter the runway but they did anyway
It might even (according to the Swiss cheese model) be a combination of all of those in some way. I suspect but can't prove, that the Coast Guard pilot made the error and entered the runway when told to hold short.
Japanese ATC / Ground Control communicate in English, it's very possible that the coast guard pilots are not used to English instructions
whatever happened, the JAL crew performed perfectly. The "Startle" affect could've disrupted their landing to the point they hit the TOGA button and that plane would have blown up in the sky. Instead, they proceeded with their landing with a millisecond to make that decision.
I'm actually at Haneda airport now. Flight in was diverted to Osaka with no explanation other than the airport being closed. Then a few minutes before touchdown we climbed out and continued on to Haneda. Waiting for my luggage and if I hadn't had lots of concerned messages I'd have had no idea there'd been a crash.
yeah, assuming they saw it before touching down it seems like their decision to land anyway (if it was actually a decision) worked reasonably well for the occupants of their plane
do you mean from my comment if they'd pushed the TOGA? That's a go around and they'd have started climbing, but they were already damaged and on fire. Had they climbed, there would have been no chance of a safe landing.
There's no need for physical barriers, there is a very clear line that aircraft are absolutely forbidden to cross without permission. GC will tell them to "hold short" and they must stop at that line. They may get a "Line up and wait" which is permission to proceed to the runway but once there they have to wait for the clearance. If you've ever been on a plane that taxi's straight on to the runway and immediately takes off without stopping, they've had "Cleared for take off runway 27 right, no delay", which means they have to go immediately.
The wording used is designed to be clear and unambiguous.
It'll be a year or more before the report comes out but if the flight is stable at minimums, they continue to the landing, usually they'd be watching their instruments at that point rather than looking out the window for an encroaching aircraft.
Blancolirio and VASAviation should have updates later on YouTube. The ATC communications will be most interesting
there are hundreds of thousands of flights globally a day, runway encroachment is extraordinarily rare.
The part that could have caused confusion is, Japanese civil aviation communication is exclusively in English. The Coast Guard probably uses Japanese in their normal routines. JAL and ANA pilots will only communicate with each other in English from the moment they start the engines, this is to prevent introducing ambiguity in translations. Once above 10,000 feet, they can relax a bit and speak with each other in Japanese but once they go below 10,000 they will be back to exclusively English.
These rules are as a result of historic errors around the globe.
Oh wow, just saw the NY times video of the impact. They were virtually on the ground when they hit, but yes, if they had tried to go around that looks like it would have been very bad, big fire right from the off
yeah, the video is shocking. Airbus are getting a lot of credit for the build quality of the A350 that it remained structurally sound enough to land and evacuate
By pure coincidence I watched the documentary at the weekend of the 1985 manchester airport runway fire...something I was slightly too young to remember properly. Google it or watch the discovery documentary. The measures which were put in place following that disaster undoubtedly saved people in this accident.
Amazing that 370-odd people were safely evacuated from this plane. Dense seating arrangement. Middle and rear doors unusable. Partly collapsed landing gear. Widespread high intensity fire.
"An aviation analyst said the accident was "a defining moment in the history of civil aviation" because it brought about industry-wide changes to the seating layout near emergency exits, fire-resistant seat covers, floor lighting, fire-resistant wall and ceiling panels, more fire extinguishers and clearer evacuation rules."
from watching the investigation documentary they also widened the minimum gap between the galley and the exit by about 10 inches which made a huge difference. following the Manchester tragedy they recreated the panic by putting volunteers on a plane and then offering them cash rewards for who got off first. Much of the learnings came from this exercise.
The aviation industry is actually fascinating. There can be few other industries which debrief mistakes with quite the same thoroughness.
JAL123 is horrific. 30 mins in the air after the tail fin broke. And 50ish survivors on impact but only 4 ultimately survived as the authorities delayed rescue. I am going to stop complaining about my current mild flu.
A bit off point, but I highly recommend the Mentoir Pilot YouTube channel for all things air disaster. Some of them are unbelievable in terms of the decisions pilots made.
The aviation industry is actually fascinating. There can be few other industries which debrief mistakes with quite the same thoroughness.
If you haven’t done so already, I recommend you read Black Box Thinking by Mathew Syed. Firstly, it’s just a brilliant book exposing the benefits of acknowledging and learning from mistakes. Secondly, in illustrating how bad lawyers are at acknowledging mistakes, it introduces readers to the concept of the concept of the unindicted co-ejaculator (which wasn’t covered in my law school syllabus)
Gladwell's Outliers devotes a whole chapter to plane crashes, and the ethnic theory of them, including "mitigated speech" and 'power distance indicators".
Is that the tendency in some cultures for the first officer not to say anything which implies a criticism of the captain even though the f/o knows it's all about to go to shit completely?
Have any of you been to the flight simulator place in Leighton Buzzard? You can fly a 737 simulator or a WWII fighter experience where you choose the Messerschmitt or Spitfire.
That was a particular problem in Taiwan I believe Buzz, and one contributing factor to its poor safety record (though this has improved in recent decades). Two problems: firstly it’s a very Confucian society even by east asian standards, and deference to elders and seniors is - or was - a key cultural principle; secondly, most pilots were recruited from the military, meaning civil aviation had quite a militaristic command culture, and speaking contrary to a senior officer was tactily frowned upon. Air force culture has generally proven a very poor model for civil aviation, even if the forces may be a good source of fundamentally talented airpeople.
Gorlami - 2024 is clearly our year for agreement. Was about to recommend Black Box Thinking myself and saw you got there first. Absolutely brilliant book.
Two of the saddest CVR reels are the air france one off Brazil, where experienced airmen appear utterly discombobulated, almost supernaturally so; and the one in the icu northeastern US winter, Loganair maybe - where it becomes obvious the two pilots are completely ill equipped by their training to fly an aircraft in any but the most serene conditions. The captain keeps pulling the stick up in the face of a stall warning. The latter was around 2010 and Inthijk it was the last fatal civil aviation accident in the US for about a decade.
the tenerife one where the KLM first officer actualky puts his hand on the throttle to stem his captain’s start of the takeoff run, and says… “…that Pan American… is he clear?”. And the grinning poster boy jock in the first seat, the airline’s most senior pilot, says “oh yes”, and rolls them forward to their doom.
Something of Dutch culture in that one, an inbuilt arrogance
Gorlami - 2024 is clearly our year for agreement. Was about to recommend Black Box Thinking myself and saw you got there first. Absolutely brilliant book.
I’m getting bit emotional here Jim. Glad we found common ground over one of my favourite books. I must have bought it and given it to about 10 friends/family members by now (Blink by Malcolm Gladwell would be the only other that rivals BBT in terms of the number of recommendations/gifts)
Gorlami- only aviation book I ever bought my father (an RAF pilot and air accident investigator) as I thought most of the stuff out there he would think was patronising. He loved it too.
My force introduced us to it and gave us free copies but, imo, failed completely to live up to the principles it was teaching.
I only recently learned that the crash wasn’t actually at the Tenerife airport that I’ve flown into so many times for holidays. That’s Tenerife Sud, which wasn’t built in 1977. It was at what is now Tenerife Nord, which is in a very fog prone location between the hills above Santa Cruz
being an air crash investigator is prob my dream job - need extreme quals tho in terms of either personal aviation experience or PHD level engineering or human factors expertise
Yeah, I could see law firms doing the same Jim. One of those messages that are easy to parrot but much less comfortable to be true to in practice. Fortunately I work for a company where it’s practically a badge of honour to talk candidly about your own mistakes and what you learned from them
yes, both planes originally bound for Gran Canaria. The accident only happened because the small size of the Tenerife apron meant the Pan Am couldn’t take off when scheduled because it couldn’t get around where the refuelling KLM was parked.
yeah Buzz, I watch them all. Blancolirio has a video up about this one already, they've only got one scrap of audio from ATC telling the Dash 8 to proceed to "holding point Charlie 5" but no response from the pilot and no apparent instruction to "Hold at Charlie 5". VASAviation doesn't have the audio either so it looks like it was pulled by authorities before LiveATC.net got hold of it.
AF447 is a very good example of "startle" factor combined with loss of spatial awareness and poor CRM.
Definitely a fascinating subject, but still surprised at the level of air crash geekery on display here.
Didn’t realise it was such a mainstream subject.
I remember attending a talk a few years ago about how the way the surgical profession responds to accidents (close rank and cover @rse) is so very different from aviation approach (full investigation and learn from mistakes), and that progress in surgical safety is much, much slower as a result.
the outcome of the investigations are not always clear. There was an Egypt Air (flight 990) crash several years ago that on the face of it looks like a pilot suicide, this is still in dispute.
Blancolirio has a video up about this one already, they've only got one scrap of audio from ATC telling the Dash 8 to proceed to "holding point Charlie 5" but no response from the pilot and no apparent instruction to "Hold at Charlie 5".
It had only just restated dual running hadn't it? So (speculating) maybe the Coastguard pilot hadn't properly clocked that there'd be anyone landing and wasn't expecting to need to hold short.
I was always terrified of take offs between 737s landing. "Mike Xray Sierra, EXPEDITE!!" 🤪
they're spaced very well generally. Heathrow was a bit chaotic last night with the storm, many planes in holding patterns. One plane, a Cathay Pacific jet, had 3 attempts landing at Heathrow but in the end went to Gatwick.
I watched Die Hard 2 over Christmas and there's so much wrong in that movie.. but I still love it..
I remember attending a talk a few years ago about how the way the surgical profession responds to accidents (close rank and cover @rse) is so very different from aviation approach (full investigation and learn from mistakes), and that progress in surgical safety is much, much slower as a result
Terry - it may have changed a lot since Black Box Thinking was published but the book conveys law and medicine as the two professions that have most room for improvement in terms of learning from mistakes and creating systems to encourage disclosure/learning & preventative steps.
Somehow for me one of the most chilling aspects of that footage is all of the ordinary activity in the foreground that continues in the minute or so after the impact and the explosion..... I imagine from their perspective on the ground the flames etc would not have been so immediately obvious, but it is extraordinary to me how catastrophe can occur so close by and not be noticed (which actually has an interesting legal implication in terms of what even proximate witnesses to an event may or may not see, notice, remember accurately...)
Everything on the apron is coordinated though. You do what you're told when you're told sonic you've been told to push back you push back. And the dude driving the tractor isn't going to hear anything because he'll have his headphones on. The pilots might see something but they're either moving where they have been told to or can't do anything because they're being pushed or pulled by a tractor. It's not a normal environment. Bear in mind also there's loads of flashing lights and a lot of noise.
Yes, and even the emergency crews have to co-ordinate their movements. They can't just rush to the scene like you see in the movies. They can't just go screaming out in front of another aircraft. There was a Asiana Air crash in SF a few years ago where a passenger who had survived the crash was run over and killed by one of the fire crews. (You may remember this incident from the TV broadcast where they said they had the names of the crew, see this MAJOR NEWS BLOOPER NAMING PILOTS OF DOWNED ASIANA FLIGHT (youtube.com)
Would anyone care to explain/speculate why the main fuselage of the Airbus has been reduced to ashes but the wings are largely intact? Intuitively (and entirely un-expertly) I would have expected that the wings which (I believe) contain the fuel tanks would be far more likely to burn....
the fuselage of an Airbus is mostly carbon fibre and the wings mostly aluminium. The fire wasn't caused by the fuel on the A350 though, the remains of the Dash 8 were under the fuselage and that plane was the source of the fire.
William Langwiesche, an ex pilot himself, has written a couple of great articles on air crashes including AF447, the contested Egyptair one, and I think also the 737 Max scandal
“Would anyone care to explain/speculate why the main fuselage of the Airbus has been reduced to ashes but the wings are largely intact?”
Reminds me of an industrial disaster in the US, the Hamlet chicken processing plant fire, where people were trapped and killed by fire and smoke in a factory. The only effective fire suppressant system in the entire place was directly above the two main deep fat fryers, massive contraptions, which had a brand new CO2 suppressant system directly above it. So effective was this, that when the fire brigade finally got inside and waded through the blackened wreckage and charred bodies, they found the two metres-long vats of cooking fat completely unburned.
Given that the pilot managed to escape from it I'd assumed it was more of a glancing blow. Reminds me of a local who got hit by an HGV at night and he was dragged along by it to the point where it took the police a while to work out some bits of the body were missing and they finally found some of him a couple of hundred meters back down the road.
apologies Cockpit, I knew that but completely forgot it...
re: dragging, at least some of it was dragged. If you watch the video, you'll see burning wreckage at the impact point. There's an interesting dent on the cowling of the left hand engine of the A350, possibly from the Dash 8's tail fin but I'm speculating on that.
Given that the pilot managed to escape from it I'd assumed it was more of a glancing blow.
The Dash 8 was lined up on the centreline of the runway waiting for T/O, the A350 basically landed on top of the poor buggers and split the Dash in two. That the pilot survived at all is dumb luck. That the A350 touched down where it did and hadn't lowered its nose further before impact is also dumb luck.
This is a useful visualisation of how they might have hit:
Just rounding up to say that the “Loganair” crash I referred to above was actually Colganair operating as Continental Connect, 2008. 50 dead including one on the ground.
Although ice was initially thought to have been involved, it was actually a pure human factors accident caused by improper pilot reaction to stalk warnings induced by unnecessarily low speed. A hugely influential accident not so much in terms of the introduction of new rules, but a focus on standards in the regionals sector where poorly trained and poorly paid pilots were being made up to captain after as little as 9months in the second chair. The pilots involved in this one, an inexperienced first officer just out of training (and feeling ill) and a seemingly talentless airman at captain who’d failed three check flights, were hopelessly out of their depth.
Although, this interesting article suggests that the fundamental error involved in the Colganair wipeout - pulling back on the stick when alarmed by a stall - seems to occur among pilots of all experience levels, sometimes to very competent ones, and especially when close to the ground:
Although, this interesting article suggests that the fundamental error involved in the Colganair wipeout - pulling back on the stick when alarmed by a stall - seems to occur among pilots of all experience levels, sometimes to very competent ones, and especially when close to the ground:
That was the ultimate cause in AF 447 - it's just that with the joystick controls in Airbus planes the other pilots (there were 3) weren't aware that the PIC was gving constant "nose up" input -> stall.
If any of them had been aware what the PIC was doing they should have used the joystick priority button and then twotted him over the head with the cockpit fire extinguisher,
Yes, there is a bit where the captain returns to the cockpit and, as a momentary outside observer of the situation, he seems to restore lucidity by realising that the nose is up - but he communicates it wrongly saying “you’re climbing”, when he hat he meant was the nose was up but in fact they were falling in a stall. As you say nobody realised that he pilot in control was constantly pulling back. They had all the time in the world to rectify it if they’d realised what is going on.
I wonder if there are any accidents in recent times which could not have been prevented with hindsight? I'm not sure weather etc has ever been the sole contributory factor...and even then arguably could have been avoided?
or other factors outside of anyone's control. I watched the NatGeo episode on Sully yesterday and it doesn't seem like much could have prevented that. The geese were not native so couldn't have been culled. The main improvement seemed to be don't give pilots 10 pages of steps to take when they only have 30 seconds to make decision. Though they are currently trialing bird radar systems to track birds like they do storms,
These speculative diagrams are very impressive and interesting - if nothing else they illustrate the relative sizes of the aircraft (essentially a Smart Car being squished by a Range Rover).
I wonder if there are any accidents in recent times which could not have been prevented with hindsight? I'm not sure weather etc has ever been the sole contributory factor...and even then arguably could have been avoided?
Since it's in the same (very roughly) area as this thread, sharing with you aviation geeks that one of the latest Revisionist History podcasts episodes (by Malcolm Gladwell) focusses on "the pilot voice" phenomenon. It's pretty interesting/entertaining. Of particular note though the cockpit recording of Cpt Sullenberger's exchange with ATC is mindblowing. How someone stays so calm in that situation absolutely amazes me. Just short, crisp responses to ATC's directions: "Unable - we'll be in the Hudson". Wow
Sully is a very calm and contemplative type of man generally and his FO was also an important part of the equation. Their CRM was outstanding and I believe its used in pilot training as a good example.
The pilots of BA009 were out of this world too, losing all four engines, flying near mountains and no visibility, they never lost their heads and landed safely. Then there was the BA flight where the captain was sucked out of the plane.. and lived. These are the reasons I trust BA so much, their crews are outstanding.
Thanks Eddie - not familiar with BA009 unless I’ve forgotten that ACI episode. sounds memorable though!
I recall the pilot being sucked out episode though. Amazing from all involved and great illustration of how such apparently small errors can have massive implications
Gorlami, it didn't crash so not sure there's an episode but it is covered widely on YT.
Yes, the simplest errors can be catastrophic, have you heard of the Gimli Glider?, the confusion was caused when the airline was switching from imperial fuel measurements to Metric.
Or the DC10 (I think in Chicago) where the engine came off because the engineers used a forklift to install the new engine and bent the attachment points
There's one particular photo taken of that DC-10 which is absolutely terrifying. There's a similar photo of a PSA 727 after a collision with a small Cessna which also makes you think what the passengers must have been thinking in those final moments. fooking awful.
It amazed me at the time that the chap was sucked out that the windows were installed in such a way that it could happen. I had also rather assumed that the speed of the plane through the air would be enough to push the cockpit windows into place rather that the pressure differential trying to pull them out all the time.
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I wouldn't be so quick to blame ATC (Ground Control) tbh. From what I can tell so far, the coast guard plane was either on, or going on to the runway as the JAL was landing. There are a number of possibilities
JAL didn't have clearance to land but thought they did
Ground Control cleared the coast guard to enter the runway
Ground Control cleared them to enter the runway but their departure was delayed thus JAL should've gone around - if they were told to go around, it might have been too late for the engines to spool up enough power to avoid the other plane.
Ground Control didn't clear them to enter the runway but they did anyway
It might even (according to the Swiss cheese model) be a combination of all of those in some way. I suspect but can't prove, that the Coast Guard pilot made the error and entered the runway when told to hold short.
Japanese ATC / Ground Control communicate in English, it's very possible that the coast guard pilots are not used to English instructions
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whatever happened, the JAL crew performed perfectly. The "Startle" affect could've disrupted their landing to the point they hit the TOGA button and that plane would have blown up in the sky. Instead, they proceeded with their landing with a millisecond to make that decision.
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I'm actually at Haneda airport now. Flight in was diverted to Osaka with no explanation other than the airport being closed. Then a few minutes before touchdown we climbed out and continued on to Haneda. Waiting for my luggage and if I hadn't had lots of concerned messages I'd have had no idea there'd been a crash.
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Odds on is a mistake by one of the crews - probably a navigating mistake by the smaller plane when taxiing.
Could have been many more casualties but very sad that five lives have been lost.
Reminds us that aviation still relies on great human skill and judgment to be safe.
They really ought to have pop up barriers that prevent taxiing on to “live” runways, at least at big airports
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why would the plane have blown up in the air? serious Q
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Because it would still have hit the smaller plane, during the TO bit of TOGA.
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yeah, assuming they saw it before touching down it seems like their decision to land anyway (if it was actually a decision) worked reasonably well for the occupants of their plane
not sure if that’s how it actually played out tho
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do you mean from my comment if they'd pushed the TOGA? That's a go around and they'd have started climbing, but they were already damaged and on fire. Had they climbed, there would have been no chance of a safe landing.
There's no need for physical barriers, there is a very clear line that aircraft are absolutely forbidden to cross without permission. GC will tell them to "hold short" and they must stop at that line. They may get a "Line up and wait" which is permission to proceed to the runway but once there they have to wait for the clearance. If you've ever been on a plane that taxi's straight on to the runway and immediately takes off without stopping, they've had "Cleared for take off runway 27 right, no delay", which means they have to go immediately.
The wording used is designed to be clear and unambiguous.
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It'll be a year or more before the report comes out but if the flight is stable at minimums, they continue to the landing, usually they'd be watching their instruments at that point rather than looking out the window for an encroaching aircraft.
Blancolirio and VASAviation should have updates later on YouTube. The ATC communications will be most interesting
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yeah I know all that, but language can always be misunderstood in a way that a steel barrier can’t be taxied over
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there are hundreds of thousands of flights globally a day, runway encroachment is extraordinarily rare.
The part that could have caused confusion is, Japanese civil aviation communication is exclusively in English. The Coast Guard probably uses Japanese in their normal routines. JAL and ANA pilots will only communicate with each other in English from the moment they start the engines, this is to prevent introducing ambiguity in translations. Once above 10,000 feet, they can relax a bit and speak with each other in Japanese but once they go below 10,000 they will be back to exclusively English.
These rules are as a result of historic errors around the globe.
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Not a great start to 2024 for Japan.
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Oh wow, just saw the NY times video of the impact. They were virtually on the ground when they hit, but yes, if they had tried to go around that looks like it would have been very bad, big fire right from the off
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yeah, the video is shocking. Airbus are getting a lot of credit for the build quality of the A350 that it remained structurally sound enough to land and evacuate
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By pure coincidence I watched the documentary at the weekend of the 1985 manchester airport runway fire...something I was slightly too young to remember properly. Google it or watch the discovery documentary. The measures which were put in place following that disaster undoubtedly saved people in this accident.
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Amazing that 370-odd people were safely evacuated from this plane. Dense seating arrangement. Middle and rear doors unusable. Partly collapsed landing gear. Widespread high intensity fire.
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see above
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there's no plane disaster documentary I haven't seen...
The worst air disaster in my book was the JAL flight 123... a terrifying joyride in a 747
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"An aviation analyst said the accident was "a defining moment in the history of civil aviation" because it brought about industry-wide changes to the seating layout near emergency exits, fire-resistant seat covers, floor lighting, fire-resistant wall and ceiling panels, more fire extinguishers and clearer evacuation rules."
from watching the investigation documentary they also widened the minimum gap between the galley and the exit by about 10 inches which made a huge difference. following the Manchester tragedy they recreated the panic by putting volunteers on a plane and then offering them cash rewards for who got off first. Much of the learnings came from this exercise.
The aviation industry is actually fascinating. There can be few other industries which debrief mistakes with quite the same thoroughness.
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Could have just started a rumour there was only one passport control desk open.
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JAL123 is horrific. 30 mins in the air after the tail fin broke. And 50ish survivors on impact but only 4 ultimately survived as the authorities delayed rescue. I am going to stop complaining about my current mild flu.
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Eddie, presumably you watch a fair few YouTube channels on this? TFC? Allec Joshua Ibay? Curious Pilot is newer but quite good.
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A bit off point, but I highly recommend the Mentoir Pilot YouTube channel for all things air disaster. Some of them are unbelievable in terms of the decisions pilots made.
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Love this thread. Guess my flightradar24 silver membership isn't gonna be enough to boss it though.
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Yeah, he's good too.
And on the less disastrous side but stunning video (and pilot) - DutchPilotGirl ./.
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Sorry “Mentour”. Plus points for the Flemish accent adding comedy gold to terrible luck/piloting.
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If you haven’t done so already, I recommend you read Black Box Thinking by Mathew Syed. Firstly, it’s just a brilliant book exposing the benefits of acknowledging and learning from mistakes. Secondly, in illustrating how bad lawyers are at acknowledging mistakes, it introduces readers to the concept of the concept of the unindicted co-ejaculator (which wasn’t covered in my law school syllabus)
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co-ejaculator sounds like a night at the swinging club
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Gladwell's Outliers devotes a whole chapter to plane crashes, and the ethnic theory of them, including "mitigated speech" and 'power distance indicators".
JAL suffered a lot from this back in the day.
Absolutely fascinating reading.
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Is that the tendency in some cultures for the first officer not to say anything which implies a criticism of the captain even though the f/o knows it's all about to go to shit completely?
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agree re JAL123
terrifying
I likewise have completed the internet insofar as air crash documentaries are concerned
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Absolutely Buzz.
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Although if you want to scare yourself, read the cockpit transcript of that Air France plane crash off Brazil.
Basically, two highly experienced pilots accidentally conspired to fly a perfectly sound airframe into the sea.
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Have any of you been to the flight simulator place in Leighton Buzzard? You can fly a 737 simulator or a WWII fighter experience where you choose the Messerschmitt or Spitfire.
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The ones that haunt me the most are the ones with CVR, JAL 123 being one but Comair 3272 is grim beyond belief.
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That was a particular problem in Taiwan I believe Buzz, and one contributing factor to its poor safety record (though this has improved in recent decades). Two problems: firstly it’s a very Confucian society even by east asian standards, and deference to elders and seniors is - or was - a key cultural principle; secondly, most pilots were recruited from the military, meaning civil aviation had quite a militaristic command culture, and speaking contrary to a senior officer was tactily frowned upon. Air force culture has generally proven a very poor model for civil aviation, even if the forces may be a good source of fundamentally talented airpeople.
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Gorlami - 2024 is clearly our year for agreement. Was about to recommend Black Box Thinking myself and saw you got there first. Absolutely brilliant book.
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Ordered, thanks. Someone had recommended it to me before, but I'd forgotten about it.
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Two of the saddest CVR reels are the air france one off Brazil, where experienced airmen appear utterly discombobulated, almost supernaturally so; and the one in the icu northeastern US winter, Loganair maybe - where it becomes obvious the two pilots are completely ill equipped by their training to fly an aircraft in any but the most serene conditions. The captain keeps pulling the stick up in the face of a stall warning. The latter was around 2010 and Inthijk it was the last fatal civil aviation accident in the US for about a decade.
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The same issue with a couple of Korean Air disasters Laz.
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the tenerife one where the KLM first officer actualky puts his hand on the throttle to stem his captain’s start of the takeoff run, and says… “…that Pan American… is he clear?”. And the grinning poster boy jock in the first seat, the airline’s most senior pilot, says “oh yes”, and rolls them forward to their doom.
Something of Dutch culture in that one, an inbuilt arrogance
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I’m getting bit emotional here Jim. Glad we found common ground over one of my favourite books. I must have bought it and given it to about 10 friends/family members by now (Blink by Malcolm Gladwell would be the only other that rivals BBT in terms of the number of recommendations/gifts)
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There are only two things I can't stand in this world: People who are intolerant of other people's cultures, and the Dutch
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Excellent - let me know what you think when you’ve read it
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Gorlami- only aviation book I ever bought my father (an RAF pilot and air accident investigator) as I thought most of the stuff out there he would think was patronising. He loved it too.
My force introduced us to it and gave us free copies but, imo, failed completely to live up to the principles it was teaching.
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I only recently learned that the crash wasn’t actually at the Tenerife airport that I’ve flown into so many times for holidays. That’s Tenerife Sud, which wasn’t built in 1977. It was at what is now Tenerife Nord, which is in a very fog prone location between the hills above Santa Cruz
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Diversions after a tezza bombing wasn't it?
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unbelievably jealous of jim’s dad’s latter career
being an air crash investigator is prob my dream job - need extreme quals tho in terms of either personal aviation experience or PHD level engineering or human factors expertise
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Yeah, I could see law firms doing the same Jim. One of those messages that are easy to parrot but much less comfortable to be true to in practice. Fortunately I work for a company where it’s practically a badge of honour to talk candidly about your own mistakes and what you learned from them
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yes, both planes originally bound for Gran Canaria. The accident only happened because the small size of the Tenerife apron meant the Pan Am couldn’t take off when scheduled because it couldn’t get around where the refuelling KLM was parked.
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Laz - his was the first. Never even finished his degree but flew thousands of hours in various fighterframes.
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Yeah, the only crappy day of my tour of the Canaries 2 years ago was going for a hike around the hills just north of TFN. Pretty much zero visibility.
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yeah Buzz, I watch them all. Blancolirio has a video up about this one already, they've only got one scrap of audio from ATC telling the Dash 8 to proceed to "holding point Charlie 5" but no response from the pilot and no apparent instruction to "Hold at Charlie 5". VASAviation doesn't have the audio either so it looks like it was pulled by authorities before LiveATC.net got hold of it.
AF447 is a very good example of "startle" factor combined with loss of spatial awareness and poor CRM.
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You aviation geeks got me thinking about my favourite Air Crash Investigation episodes again and I remembered this one:
https://en.wikipedia.org/wiki/Helios_Airways_Flight_522
Absolutely harrowing to think of what Andreas Prodromou went through in the last 15 mins on his life.
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Definitely a fascinating subject, but still surprised at the level of air crash geekery on display here.
Didn’t realise it was such a mainstream subject.
I remember attending a talk a few years ago about how the way the surgical profession responds to accidents (close rank and cover @rse) is so very different from aviation approach (full investigation and learn from mistakes), and that progress in surgical safety is much, much slower as a result.
Will read that Syed book.
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the outcome of the investigations are not always clear. There was an Egypt Air (flight 990) crash several years ago that on the face of it looks like a pilot suicide, this is still in dispute.
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It had only just restated dual running hadn't it? So (speculating) maybe the Coastguard pilot hadn't properly clocked that there'd be anyone landing and wasn't expecting to need to hold short.
I was always terrified of take offs between 737s landing. "Mike Xray Sierra, EXPEDITE!!" 🤪
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'kinell, it was stopped on the runway for aaaaages:
JA772A + JL516 CRASH EXTENDED FOOTAGE - Tokyo Airport HND/RJTT - YouTube
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they're spaced very well generally. Heathrow was a bit chaotic last night with the storm, many planes in holding patterns. One plane, a Cathay Pacific jet, had 3 attempts landing at Heathrow but in the end went to Gatwick.
I watched Die Hard 2 over Christmas and there's so much wrong in that movie.. but I still love it..
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Terry - it may have changed a lot since Black Box Thinking was published but the book conveys law and medicine as the two professions that have most room for improvement in terms of learning from mistakes and creating systems to encourage disclosure/learning & preventative steps.
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Interesting, thanks
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Somehow for me one of the most chilling aspects of that footage is all of the ordinary activity in the foreground that continues in the minute or so after the impact and the explosion..... I imagine from their perspective on the ground the flames etc would not have been so immediately obvious, but it is extraordinary to me how catastrophe can occur so close by and not be noticed (which actually has an interesting legal implication in terms of what even proximate witnesses to an event may or may not see, notice, remember accurately...)
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Everything on the apron is coordinated though. You do what you're told when you're told sonic you've been told to push back you push back. And the dude driving the tractor isn't going to hear anything because he'll have his headphones on. The pilots might see something but they're either moving where they have been told to or can't do anything because they're being pushed or pulled by a tractor. It's not a normal environment. Bear in mind also there's loads of flashing lights and a lot of noise.
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Yes, and even the emergency crews have to co-ordinate their movements. They can't just rush to the scene like you see in the movies. They can't just go screaming out in front of another aircraft. There was a Asiana Air crash in SF a few years ago where a passenger who had survived the crash was run over and killed by one of the fire crews. (You may remember this incident from the TV broadcast where they said they had the names of the crew, see this MAJOR NEWS BLOOPER NAMING PILOTS OF DOWNED ASIANA FLIGHT (youtube.com)
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Would anyone care to explain/speculate why the main fuselage of the Airbus has been reduced to ashes but the wings are largely intact? Intuitively (and entirely un-expertly) I would have expected that the wings which (I believe) contain the fuel tanks would be far more likely to burn....
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On landing I guess they wouldn't have had much fuel left them in and they're largely still metal versus the lovely burny plastic of the interior.
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the fuselage of an Airbus is mostly carbon fibre and the wings mostly aluminium. The fire wasn't caused by the fuel on the A350 though, the remains of the Dash 8 were under the fuselage and that plane was the source of the fire.
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William Langwiesche, an ex pilot himself, has written a couple of great articles on air crashes including AF447, the contested Egyptair one, and I think also the 737 Max scandal
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“Would anyone care to explain/speculate why the main fuselage of the Airbus has been reduced to ashes but the wings are largely intact?”
Reminds me of an industrial disaster in the US, the Hamlet chicken processing plant fire, where people were trapped and killed by fire and smoke in a factory. The only effective fire suppressant system in the entire place was directly above the two main deep fat fryers, massive contraptions, which had a brand new CO2 suppressant system directly above it. So effective was this, that when the fire brigade finally got inside and waded through the blackened wreckage and charred bodies, they found the two metres-long vats of cooking fat completely unburned.
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The wings on an A350 are made of composites, not metal.
HTH
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composite and carbon fibre both burn fti
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fyi even
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the fan blades will be forged steel, I worked on a buyout of a company (Forth Rixson plc) whose main product was steel fan blades
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"The fire wasn't caused by the fuel on the A350 though, the remains of the Dash 8 were under the fuselage and that plane was the source of the fire"
Do you think that the Dash was dragged along the runway under the A350? Dont suppose it made much difference to those inside, but yuck.
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Given that the pilot managed to escape from it I'd assumed it was more of a glancing blow. Reminds me of a local who got hit by an HGV at night and he was dragged along by it to the point where it took the police a while to work out some bits of the body were missing and they finally found some of him a couple of hundred meters back down the road.
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Laz, the fan blades in a Trent XWB94 are titanium, not forged steel.
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According to Wikipedia, 4.1% of all Boeing 747s have been lost in “accidents or incidents”.
That struck me as a surprisingly high percentage.
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apologies Cockpit, I knew that but completely forgot it...
re: dragging, at least some of it was dragged. If you watch the video, you'll see burning wreckage at the impact point. There's an interesting dent on the cowling of the left hand engine of the A350, possibly from the Dash 8's tail fin but I'm speculating on that.
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that would be unusual, bbombby
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The Dash 8 was lined up on the centreline of the runway waiting for T/O, the A350 basically landed on top of the poor buggers and split the Dash in two. That the pilot survived at all is dumb luck. That the A350 touched down where it did and hadn't lowered its nose further before impact is also dumb luck.
This is a useful visualisation of how they might have hit:
https://www.pprune.org/accidents-close-calls/656665-jal-incident-haneda-airport.html#post11567943
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Just rounding up to say that the “Loganair” crash I referred to above was actually Colganair operating as Continental Connect, 2008. 50 dead including one on the ground.
Although ice was initially thought to have been involved, it was actually a pure human factors accident caused by improper pilot reaction to stalk warnings induced by unnecessarily low speed. A hugely influential accident not so much in terms of the introduction of new rules, but a focus on standards in the regionals sector where poorly trained and poorly paid pilots were being made up to captain after as little as 9months in the second chair. The pilots involved in this one, an inexperienced first officer just out of training (and feeling ill) and a seemingly talentless airman at captain who’d failed three check flights, were hopelessly out of their depth.
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Although, this interesting article suggests that the fundamental error involved in the Colganair wipeout - pulling back on the stick when alarmed by a stall - seems to occur among pilots of all experience levels, sometimes to very competent ones, and especially when close to the ground:
https://airfactsjournal.com/2023/06/how-not-to-lose-control-what-we-can-learn-from-colgan-3407/
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That was the ultimate cause in AF 447 - it's just that with the joystick controls in Airbus planes the other pilots (there were 3) weren't aware that the PIC was gving constant "nose up" input -> stall.
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If any of them had been aware what the PIC was doing they should have used the joystick priority button and then twotted him over the head with the cockpit fire extinguisher,
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Yes, there is a bit where the captain returns to the cockpit and, as a momentary outside observer of the situation, he seems to restore lucidity by realising that the nose is up - but he communicates it wrongly saying “you’re climbing”, when he hat he meant was the nose was up but in fact they were falling in a stall. As you say nobody realised that he pilot in control was constantly pulling back. They had all the time in the world to rectify it if they’d realised what is going on.
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I wonder if there are any accidents in recent times which could not have been prevented with hindsight? I'm not sure weather etc has ever been the sole contributory factor...and even then arguably could have been avoided?
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There are a few wind shear related accidents and I’m not sure there’s much you can do about massive and sudden wind shear on final approach
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but, other than that - I’m not aware of many pure weather accidents no
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or other factors outside of anyone's control. I watched the NatGeo episode on Sully yesterday and it doesn't seem like much could have prevented that. The geese were not native so couldn't have been culled. The main improvement seemed to be don't give pilots 10 pages of steps to take when they only have 30 seconds to make decision. Though they are currently trialing bird radar systems to track birds like they do storms,
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This is a useful visualisation of how they might have hit:
https://www.pprune.org/accidents-close-calls/656665-jal-incident-haneda-airport.html#post11567943
These speculative diagrams are very impressive and interesting - if nothing else they illustrate the relative sizes of the aircraft (essentially a Smart Car being squished by a Range Rover).
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"I wonder if there are any accidents in recent times which could not have been prevented with hindsight?"
I was about to suggest SR111. Not much you can do about fire.
But it turns out they delayed landing to dump fuel and didn't really know what was going on. Even so, hard to imagine that was survivable.
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The 737MAX crashes
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Since it's in the same (very roughly) area as this thread, sharing with you aviation geeks that one of the latest Revisionist History podcasts episodes (by Malcolm Gladwell) focusses on "the pilot voice" phenomenon. It's pretty interesting/entertaining. Of particular note though the cockpit recording of Cpt Sullenberger's exchange with ATC is mindblowing. How someone stays so calm in that situation absolutely amazes me. Just short, crisp responses to ATC's directions: "Unable - we'll be in the Hudson". Wow
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Sully is a very calm and contemplative type of man generally and his FO was also an important part of the equation. Their CRM was outstanding and I believe its used in pilot training as a good example.
The pilots of BA009 were out of this world too, losing all four engines, flying near mountains and no visibility, they never lost their heads and landed safely. Then there was the BA flight where the captain was sucked out of the plane.. and lived. These are the reasons I trust BA so much, their crews are outstanding.
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Thanks Eddie - not familiar with BA009 unless I’ve forgotten that ACI episode. sounds memorable though!
I recall the pilot being sucked out episode though. Amazing from all involved and great illustration of how such apparently small errors can have massive implications
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The.....er......pilot voice.......episode was....er.....rather good.
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Gorlami, it didn't crash so not sure there's an episode but it is covered widely on YT.
Yes, the simplest errors can be catastrophic, have you heard of the Gimli Glider?, the confusion was caused when the airline was switching from imperial fuel measurements to Metric.
Or the DC10 (I think in Chicago) where the engine came off because the engineers used a forklift to install the new engine and bent the attachment points
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There's one particular photo taken of that DC-10 which is absolutely terrifying. There's a similar photo of a PSA 727 after a collision with a small Cessna which also makes you think what the passengers must have been thinking in those final moments. fooking awful.
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It amazed me at the time that the chap was sucked out that the windows were installed in such a way that it could happen. I had also rather assumed that the speed of the plane through the air would be enough to push the cockpit windows into place rather that the pressure differential trying to pull them out all the time.
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