Wrong decisions - Air Vanuatu flight 241
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- Опубликовано: 27 ноя 2024
- This is the story about how an engine problem escalated into problems involving another four aircraft systems, simply because wrong decisions were made along the way. The aircraft lost directional control during landing and ended outside the runway. Thankfully, everybody on board escaped without injury.
This accident leaves a question about how pilots are trained in smoke scenarios. Are the simulators realistic enough, and does the training prepare us for the real world? Please leave a comment below and let us know what you mean about this.
Links:
Accident report: www.aic.gov.pg...
Interview with Dan McGarry: danmcgarry.sub...
Electrical systems • ATR electric systems -...
Hydraulic systems • ATR systems - Hydraulics
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Wow, I came from Mentour Pilot, and love your videos. I work in IT security. There is less time pressure there, but multiple failures, misunderstanding of system interactions, lack of teamwork (CRM), and lack of preparedness leads to lots of failures there too.
Welcome. Sadly, there are many accidents where it is the experienced captain who messes things up. When I work with these videos, it reminds me to be humble and listen to the first officer. Every flight is a learning process.
I am from Vanuatu and have been questioning why a beloved aircraft had an accident. This is very informative and the analysis is spot on. Indeed checklists are very important and sure applying reverse thrust caused more damage than intended, I do not fly but I am an avid aircraft spotter for business and fighter aircrafts including armed materials.... FYI the aircraft is now a wreck sitting at then end of the runway :-(
Mr. Nordal, congratulations for this terrific channel. I love the way you explain things clearly and with objectivity. It's a good thing Mentour Pilot linked your channel in his Al-Hoceima incident video. Keep the good work up, way to go sir.
This is a very nice video with a lot of analysis, very well presented.
This exemplifies how not performing NNCs in a timely and correct manner can create a snowball effect. It does look like the captain lost his ability to analyse the situation early on - as you said very rightly, taking control immediately in this situation likely didn't help. His subsequent CRM (teamwork, communication, handling of checklists, SA, decision making...) was below what one would expect, to put it nicely.
I'm not familiar with ATRs, having flown only Boeing products. However their NNCs look quite simpler to me. Notably, when the landing configuration and/or technique is affected, the NNC includes the descent, approach and landing checklist... Also, they have just ONE NNC for smoke, that essentially addresses the most common causes of smoke. It deals with relatively benign stuff like recirc fans. The key point is to protect yourself and to land quickly if the source of the fire can't be positively confirmed to be suppressed early in the NNC. Should I summarise its underlying philosophy, I'd say it's designed to save the aircraft by landing quickly, not by actioning switchesand I tend to agree with that.
Here, I understand that the cause of the smoke was the engine problem and nothing else. Had the captain simply secured the engine timely, the smoke problem would have disappeared by itself or might haven't happened at all... And it was as you said quite obvious that every issue that developed after the initial engine malfunction was related to it.
Love the technical bits. Thanks for sharing.
Excellent video! I'm part way through command training at the moment on the ATR 72-600 and it's great to find resources such as what you offer on your channel. Thank you for the good work
This is an excellent video, thank you for sharing your knowledge with us young aviators. Have learnt alot from this video. Keep them coming
Thanks for putting this to light. Thumbs up 👍🏽
Captain congratulations, this is an excellent video, the explanation is clearly terrific with objectivity. Thank you for sharing your knowledge with us.
Hello Captain. I am soon to be type rated for ATR 72-500. Your videos are great to watch and have lot to learn from. Do continue making more videos. Blue skies !!
Thanks, will do!
Thank you to emphasize the tlu low speed during before landing checklist. I’ve been learning a lot with yours videos.
On -500 sometimes it is very hard to identify the hierarchy and different levels of alert. A single fault can lead to a multiple faults as they may be the consequence of it. Pilots need to carefully understand and identify the problem. While doing the checklist there might be additional fault alerts and pilots need to understand that they may be the consequence of doing the procedure. Pilots should not get distracted by these to prevent them to discontinue an active fault checklist and proceed with a new checklist for the new fault that popped out. It is very imprtant to know the plane and its systems inside and out. That gives you advantage in dealing with crisis and emergencies.
When doing checklist there is an intersting gesture called "shisa kanko". It is a Japanese gesture commonly observed in train drivers, bus drivers, technicians and even pilots. They call it "point and call" or "shisa kanko". It reduces workplace errors by as much as 85% and increases the level of safety. Pointing to things forces your eyes to follow what your index finger is pointing combined with calling out the actual position. It assures the person that everything is in the correct place and position. Some pilots especially the experienced one tends to memorize the response to a challenge on a checklist over time. They usually answer the response immediately because they memorize it, while at the same time they fail to look at the specific button, switch or lever which is in the incorrect configuration leading to a serious safety issue if not attended to. I am currently doing that practice of pointing and calling, it helps a lot and its very effective.
During my ATR training twenty years ago, the instructor emphasized the importance of pointing at the relevant indications and pushbuttons, and then ask for confirmation. This is still emphasized in ATR FCTM.
In the EFIS cockpit, when you have multiple failures, check the status of the engines. If they are fine, look for a bus failure. This philosophy works well. The glass cockpit makes things easier, but you should never forget the basics.
Hi, one of the things that does not get emphasized during training, especially during the initial where the pilot is required to learn a vast amount of information in a relatively short time, it is what the outcome of a checklist will be and how it will affect the other systems. In my opinion it is essential to review the EICAS or whatever CAS the airplane has at the completion of a checklist to check that the outcome is the expected one - in the 737 when u secure the engine after an engine failure or as you go through an abnormal checklist or when you deal with an issue, when challenged the answer is the published one, followed by RELATED, if the issue is a direct consequence of the primary failure. Once the abnormal checklist is completed and the EICAS reviewed - we actually do not have an EICAS but a fault annunciator panel - we deal with the abnormal by prioritizing based on the basic principle aviate navigate and communicate - the abnormal checklist will set the priorities for you reconfiguring the systems as you progress to it.
What was there to really understand? I am not ATR type rated. But they should have simply dealt with the engine issue sooner than they did. Even when they knew there was smoke in the cabin they couldn't figure out that it is the engine that is the problem. They made a very simple situation very complex.
Mickey Mouse and Goofy would have done a better job than those two clowns.
@@anasmaaz5731 You sound like an aviation expert. Obviously you still have a lot to learn about aviation and aircraft incidents/accidents analysis.
@@jobys4568 If you want to insult me then that is alright. I have been in the industry for quite a while now. I have flown turboprops and have over 2000 plus hours on Dash 8s and I am currently flying the A320. I think that is some what enough to know a bit of this and that. It was just my opinion. No need to get disrespectful.
If you look at the crash report you will see the same thing. They failed to to their job. And they made a mess out of it. And if you read it well you will realise that the pilots were not up to the job. You can defend anyone you want. But the damage of their failure will always be there. You cannot really hide it.
Thanks again for one more excellent vídeo.
Great video thanks Magnar
Thank you very much for your precious advice and knowledge sharing.
Very informative video. Thanks Captain
Hi, i just watched the video about the air vanuatu accident. Even though i am not type rated on the ATR as u know it, as a pilot i am trained to recognize an engine stall and surge as it will be indicated by fluctuating ITT and Nl/h, loud pulsating bangs coming from the engine which i am positive will command some memory items to be completed including reducing power/thrust on the affected engine when conditions allow and after confirmation with the other pilot: that would have partially corrected the situation and in this specific case limited the amount of smoke entering the cabin. Once the crew determined that retarding the PL did not fix the problem, they should have shut the engine down as per the qrh and be aware that when u secure an engine there are a number of systems that are affected - hydraulic, pneumatic, electrical are always affected but that applies to any airplane. It is also very important in an emergency to assign the tasks in a clear fashion so that everyone knows what to do and what the outcome of a checklist will be. One point that i would like to emphasize is the CRM refers to CREW Resource Management and that entails all the crew onboard the airplane and not only the crew in the cockpit as the cabin crew can provide essential information. If i was in the captain shoes i would have complete the memory items for the engine surge first followed by the checklist and secure the engine as that would have eliminated the root cause of the issue, then i would have called the cabin or ideally the cabin would have informed me and i would have completed the air cond smoke checklist and inform the cabin that the smoke was related to an engine problem. Then i would have declared an emergency and prepare the airplane for a single engine approach and landing and proceeded to the airport. By prioritizing the smoke checklist first they did not fix the source as the engine was not secured and the source of the smoke had not been isolated. Thanks for sharing
Another individual that writes "I would do this, I would do that".
Thanks so .. it will benefit everyone, the findings
Hello captain, It is a real pleasure to learn more and more from you. Procedures, secrets, you name it ! Thank you ! As in all aviation mistakes did they take into account alternate smoke procedures in simulators or it remained the same ?
Great job captain
"in most cases you have plenty of time..." - reminds me of the guidance:
_In case of emergency, first wind your watch._
Thanks for sharing. 😉👌🏼
Nice video 👍🏻
Just came across this ahead of the 4th anniversary of this event. Thank you for this explanation. I was a passenger on this flight with my family. There was an uncontrolled roll prior to landing, mentioned in the final report and experienced on the plane as a sudden sideways roll - was this likely due to the TLU as well?
Thank you for your message. You didn't mention when the roll happened. It could have been turbulence, or the pilot could made a sudden correction to stay on the runway centerline. If that was the case, then the TLU would not have any effect. If the roll happened just before landing, it could have happened when the pilot reacted to a crosswind. In such cases we simultaneously apply ailerons into the wind and opposite rudder. With the TLU in high-speed mode, the rudder will move a few degrees, and the result could have been an excessive roll. But I can only speculate. What matters most, is that everybody escaped unhurt.
@@FlywithMagnar thanks for your reply. No need for further analysis, but fyi, the roll occurred over land but before we were in position to make the approach to land. It is mentioned in the report but with no detail. Thanks for your informative report.
Gotta love the "I"s, " I am", If I was" in Diego Beatrice's comment. We can re-write world's history with lots of "If" and armchair chit chat. Pilots should be more of "I am glad it wasn't me", I hope I will have an uneventful career and a clean record" etc, rather than being judgmental, opinionated. What if this happened to a friend of mine? How would I react? Would I "trash" talk? Of course not. Easy done when talking about total strangers. Just think if you are in a situation doesn't go your way for whatever reason(s). Human nature is quick to judge. Objectivity is key rather than subjectivity. In incidents and accidents pilots are always on the receiving end no matter what. Pilots become ideal scape goat. Pilots can go years and years without any issues, pretty much a whole career and one day all that the individual is remembered by is that one instance and the rest is forgotten. The giveaway is how can we make training better, how can we contribute to elevate crew performance/awareness, share knowledge, prkvide moee tools to succeed, etc...Egos need to be set aside. Keep in mind Human Factors. The human brain is complex. The way reports are drafted and written is also important, the choice of words. Words such as "should have", "finally" are subjective.
Analysis can be very different depending on the event: ie. Normal ops with deliberate violation of SOP ending in an undesired outcome or Emergency/Abnormal/Non Normal with undesired outcome. Very different analysis. The first one is a deliberate action/breach which goes against the norm. The second is what can we take away from it to make things, any shortcomings, any lessons, any changes to incorporate.
Hello Captain do you teach in AATC Bangkok? Your explanation is very good! It is very detailed but simple and easy to learn even on new pilots. I hope you could be my instructor on my recurrent.
Hi, thank you, but I am not working for AATC.
I cannot contest the FO's lack of knowledge. What seems odd, though, is that the report seems to have blamed the FO for the steep authority gradient. The captain was only cited for being overdue for smoke training. Should not the captain's tech and CRM expertise have been identified as major contributing factors? After all, he's the one who had the FO jumping between checklists. Granted, a savvier FO would have pushed back (worked through the captain's shortcomings) more effectively, but it seems odd the report called out the FO but not the captain....
Why is there no smoke detector in the bleed air channels right behind the engines? …to prevent smoke entering the cabin from a faulty engine automatically.
Your answer at 13:55
Was the aircraft repairable after or was it scrapped?
It appears to have been repaired. Current status is "stored".
Any particular reason why no thrust reverse in single engine landing. I fly 737 and that's sop..I don't think that was the primary cause of the excursion... It was the lack of rudder control.
ATR recommendation is "reverse with care". Full reverse is just too much, especially at high speed.
All budding pilots out there i would seriously take on board what this captain has to say…no pun intended
Hello Magnar I sent you something on quora. Kind regards
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