How One Switch Almost Crashed This Plane | Flybe 130
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- Опубликовано: 1 сен 2023
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This is the story of flybe flight ___ on the 11th of january 2018 a fybe dash 8 was to fly from belfast city airport to glasgow airport. Flying was not something that the captain of flight - was planning on doing that day you see he was on standby and at the last moment he got the call that he would have to fly. So he immediately made his way from Aberdeen to Glasgow city airport to start off flying for the day this is when he met his first officer for the day.. This would be their first time flying together and both of them did not fly in or out of belfast quite often. But the weather was quite good for the time being and so neither pilot expected anything too challenging today. In the cockpit the two pilots prepped for the takeoff, they decided that the captain would be the one that would be flying the first two legs today and then the first officer would take over. The first flight of the day from Glasgow to Belfast was uneventful. The dash 8 made a smooth touchdown on runway 22 at Belfast and the pilots got to work turning the plane around for the flight back to glasgow. As the plane evacuated the runway the first officer was busy with his after landing checklists. The plane taxied and got to the stand a whole 5 minutes ahead of schedule. Not too shabby for the first flight of the day. Now that they had gotten the plane on the ground they now had to get the plane ready for the flight back. The captain walked around the plane conducting a visual check while the first officer programmed the flight management systems. Since the weight of the plane would change on the ground at Belfast a new load sheet had to be printed out. All of this went by without a hitch and within no time they were ready for the flight back.the controllers gave flight - its clearance, they would have to climb and maintain 3000 feet after taking off and so they programmed all of that into the autopilot. With the new load sheet information programmed in the pilots started the pushback and flight - was on its way to the runway. As the engines roared to life the flaps were set to 5 and the plane made its way to the holding line of runway 22. It was then cleared onto the runway so that it could backtrack and then lineup and take off. As they approached the threshold of runway 22 the captain went over their clearance again. He said “3000 with alt sel” then they started to turn the plane around on the runway to line up. Just as they lined up the taxi checklist was completed. In the cockpit the pilots were busty communicating with the controllers, doing the after start checks and prepping the cabin for departure. Complicating all of this was the fact that another airplane might be on arrival so they needed to takeoff soon or someone else would have to go around they would be mad. Then they moved onto the lineup checklist. Then they got the final takeoff clearance. The pilots started the takeoff roll and the dash 8 picked up speed and then it took off into the Belfast sky. Right after takeoff the Lnav mode was selected on the autopilot meaning that the autopilot would fly the plane along a pre planned path. The plane climbed away and soon it was at a1000 feet of altitude and the rate of climb was very much healthy. As the plane climbed it got engulfed by clouds and the crew were now in IMC. Now that the plane was safely climbing away the pilots turned on the autopilot. After a while something weird started to happen the plane was no longer climbing. The nose started to drop at about 1.2 degrees per second. BUt the crew were too busy with the after takeoff checklist. Over a couple of seconds the pitch of the plane went from 10 degrees nose up to 8 degrees nose down. With that they were descending. The plane was picking up speed and no on on the flight deck seemed to notice, the plane reached 4300 feet per minute of descent and then it broke though that critical altitude where the alarms would start shouting at the pilots. The automated warning just said “dont sink “ at 1300 feet. The captain wasted no time, he or she immediately disconnected the autopilot and pulled back power on the engines and pulled 
Наука
That sounds like a flaw in the system. At the very least, it's not telling the crew the whole truth.
I fly the Dash 8-400, and while the autoflight system definitely has some quirks (as do many transport category aircraft), it is relatively simple to use. There is a running joke in the training department at my work that whenever a pilot makes some sort of blunder or error using the AFCS and the aircraft does something they didn't want it to do as a result, they should make use of the phrase "stupid airplane". Jokes aside, the automation is a tool used to reduce the pilot's workload, its whole job is to follow the command bars on the flight director. It is only doing what you tell it to do. This crew appears to have found that out the hard way, but I am glad that they caught this mistake before it turned into a serious accident.
This reminds me a lot of the Emirates B777 takeoff incident in Dubai a couple years ago, where the MCP altitude was set to 0' instead of the SID altitude, and as a result when the aircraft accelerated down the runway, through V1 and later VR, the PF who was following the flight director command bars did not rotate because the FD was trying to keep the aircraft on the ground at zero feet. When they did become airborne at the very end of the pavement, the FD was then commanding a pitch down to get the a/c back down to 0', and again the PF followed the FD command bars. During this time the aircraft was also oversped and nearly collided with several buildings. Thankfully they didn't engage the autopilot before realizing their mistake in this case (inhibited on the 777 below 200') because it would have literally flown them into the ground. ANY aircraft can get you into serious trouble if you misuse the automation, don't monitor it properly, don't understand its logic or its limitations. The relationship between pilots and aircraft automation has improved significantly in recent decades, but that has come in the wake of a lot of near-accidents and accidents, and occasionally they still happen.
Where I work, the normal SOP is that the Captain will set the FD modes for takeoff (GA, HDG, ALT SEL) and the FO sets the cleared SID altitude in the altitude preselect. In the event that the clearance hasn't been obtained yet but the Captain is at the point in their flight deck preparation where they are setting the FD modes, a placeholder altitude is selected (circuit altitude in some cases, usually the expected SID alt minus 100') *before* hitting ALT SEL, this is done to prevent something like this from happening and is standard procedure at most of the DH8 operators here. After flying the aircraft for a bit, you will pretty much always be in the habit of hitting the ALT SEL button immediately after you set the altitude in the altitude preselect, because that is how you tell the aircraft to climb or descend to whatever altitude in whatever vertical FD mode you're using. If you forget to hit the ALT SEL button, the aircraft will happily climb or descend through whatever altitude you've selected, because you have not told it to level off at that altitude. That is one of a few ways the AFCS can bite you if you don't use it properly (seen that before), and that applies to any aircraft that has any degree of automation.
I had to commit to read this comment, but I’m glad I did lol. 👍🏻
I love the "stupid airplane " line!
@@jshumphress13I know right! 😂But I'm glad I did too 👍🏾
Shouldn't the Dash 8 AP code be rewritten to fix this behaviour? Or is it intended behaviour for some other situation?
Yeah, I don't understand why this hasn't been fixed. A target altitude of ZERO should cause some kind of fault or alert.
I guess it’s used to maintain a descent profile on approach, but yeah you could just use vertical speed select instead. It probably just shouldn’t allow programming under 500’ - or without a specific altitude input while on the ground and since last startup.
@@EstorilEmAlt hold should not be used for descent, in fact it's impossible for the pilots to explicitly select that mode, the plane's internal logic does that for them. There are many reasons for this, one of them has to do with the theory of automatic controls used to design the autopilot responses, stuff about linearization and setpoint values. In short, the code for ALT HLD would not be able to correctly bring the plane to the correct altitude without any issues (timing, overshoot, stability...) if the target altitude differs too much from the current one, it's just not designed to handle that large control inputs. This is the reason for ALT HLD to exist in the first place, as the inverse is also true: ALT is designed around other requirements and would not be able to reliably keep the target altitude and correct for small deviations, it would be too slow et al
@@EstorilEmusing vertical speed is a bad practice andshould be avoided
Actually the plane did what it was told. So why change that?
I was on this flight and it scared the living daylights out of me and the other passengers plus the cabin crew as well. The pilots did an exceptional job that day but as others commented, they didn't notice until the alarms sounded . There has to be a better way to go over the checklist, especially when it takes the pilots awareness of what's going on around them away. We are so lucky to be alive today.
"ATC was a bit concerned..." Ya think? :-)
I would say this is a design flaw in the autopilot.
I would agree
Rip Flybe (again)
Seems like a software issue, does anyone know if it was fixed? Even with the simulators and checklist being changed, cockpit crews have enough to deal with already. Great Video! Thank You. 😀
Seen a lot of videos where pilots were not paying attention to the artificial horizon or altimeter. Seems like there should be a subtle verbal notification "climbing" "descending" "turning left" etc. I know, I'm naive.
0:50 "a smooth touchdown" lol
my concern? the pilots were too busy doing check lists to notice the pitch change from positive to negative. First fly the plane the rest is a box ticking exercise!
Right?! I think they say aviate, navigate, communicate ✈️
I used to fly on Flybe. I really liked those Dash 8s too.
I remember this one from the news reports at the time. Didn't know the details so thanks for explaining. It's far more worrying than what was reported at the time. I stayed not far from George Best airport and my kids school was even closer. So glad this was resolved successfully.
What is sad is that it costs less to add steps to the (already cumbersome) checklists and put the pilots through extra training and work than to implement a simple software fix.
It's $1,000 to make the change, then $1,000,000 for the qualification testing and rollout.
So like to see the videos where everyone makes it out alive!
Agreed 👍🏾
One would think that there would be a safety check by the autopilot that warns when an altitude of zero is selected that would blare 'are you sure?'
Almost?
I’ll wait for the next video.
DDTis is the story-Best part of story😀
Great video!😸
This is unsettling as I’ve flown the dash 8 with Flybe many times
Love your videos
the graphics remind me of early 2000s colin mcrae rally lol
Runway 22 is the best approach at Belfast city as you approach over Belfast lough, lovely scenery
Beautiful scenery, terrible airport.
@@WhatALoadOfTosca Nice scenery awful place - source unfortunately I live there
As a Glaswegian that doesnt look like the approach to GLA however great to hear my home city in video with safe outcome.
Holy carp... maybe they aughta fix that thing before somebody bends a plane! Good episode, MACI :)
How many planes ce=rash while the crew is playing checklist?
Should there be a policy of watching the instruments for a full minute after engaging autopilot to make sure it's doing what the pilots expect?
7:55 wow that’s my birthday / I turned five in 2017 too lol❤😂
How do you make your way from Aberdeen to Glasgow? It's a three hour drive or a flight.
Belfast, Glasgow. I understand why somebody would want to leave those cities but going to one of them? Not so much
Has to be an autopilot issue.
In the UK, their reputation was so bad we called them "FlyMayBe"
0:55 lol the landing. You gotta stay on center.
Good stuff. Whats with the thumping noise througout the video?
Plz don't get me started on the audio
I didn’t hear them, it all sounded ok to me.
Bro is ripping a j
I didn't hear a thumping noise 😳
i would think after the second time the autopilot cause the plane to dive that close to the ground, the last thing I would do it to activate the autopilot again.
What happened to fly 1 3
0
What about changes to the plane's friggin useless controls?!!!!!
I would not have used The AP after it was pinpointed to being The issue. I would have flown The plane by hand, If realistically possiblr
Flybe has a strange history, and now they are not operating any more //
What flight sim is this
I’ve seen a dash 8 do a barrel roll.
Aren’t there too many buildings and trees close to that runway? 😱
*Wings stay on / Wings fall off.*
0 is a valid altitude
Anyone who doesn't think that systems introduced by modern aviation have become unpredictably and unsafely complicated in their interactions with each other and the real world... just hasn't watched enough air crash investigation videos.
Do you think AI will make it worse?
@@outofturn331 50% worse, 50% better. The main problem of AI are situations that require a creative approach. Here, the pilots' experience is decisive whether people survive or not.
@@outofturn331 It's going to depend on how it's implemented TO make it worse or better... For a maximum benefit, since we're already dabbling in AI working in code, it would stand to reason that setting AI to run Computer Modeling scenarios with existing code and see where weaknesses can be detected would be more efficient and less human hours spent on that. We already do similar, except it's much more "chaos theory driven" than is necessary...
For a break down of how code is getting improved, you can start with references to "Virtual Box" and the principle of "You gotta break it and fix how it breaks over and over"... Even the various linux based and Kali-linux related breakdowns are pretty understandable, but it's where to poke around at how it's done currently, particularly in "Pen-testing" (aka Penetration Testing as comes with the "White Hat Hackers" who do this kind of work for Code Dev's.)...
The next step is to compose an AI that just "cleans" all the internal code for efficiency. This is a little more complicated... Basically, ANY proficient Code Developer (Code Dev') is going to have false starts and dubious strings of unwanted code when a piece of software is done. This is only part of where Pen-Testing comes into play, because some of those "extraneous strings of dirt" in the code can AND WILL serve as exploits by which nefarious entities (aka "Black Hat Hackers" or "Criminals") will take advantage of a system. The other side-effect of "dirty code" is not only inefficiency of processing the extraneous stuff uselessly, but occasional and UNPREDICTABLY creating invalid states within the system that can result in catastrophic failures and shortcomings... like this situation where a switch or input used "out of turn" can dangerously integrate a VERY BAD VALUE (like "0-feet == Altitude" when at "cruise mode" for an aeroplane. You NEVER EVER want to try to cruise at 0 feet in an aeroplane!
What's worrisome is that instead of trying to integrate AI in this sort of "step by step" methodology, the corporates are more interested in trying to "rush it" into integration as a substitute for humans altogether. They keep wanting it to fly the plane when we're still at a point where it can barely crawl and walk... and only one or two WORLD-WIDE have managed to effectively jump, and even they don't give reliable results for the landing HALF of that jumping action...
There's no short-cut for effective step-by-step management. Trying to short-cut the basic "Computers are machines, and machines are stupid" principle is only ever going to be catastrophic to any business involved. ;o)
if it had been an airbus they would have all been doomed. The airbus is very unforgiving to novice pilots and is known to wrestle control from the pilots at the very last moment.
Raison d'etre of the 25000kg lighter, turbo prop plane ; for us to know, its not about the used concept / technology. Anything can crash, anytime ..
So you got a system that has a flaw that's easy to trigger, with three prior incidents.
I dunno, Canada's done this before, hello there Thorac 25 and the whole fustercluck around that, and now the Dash 8 Q400 and the same general issue. It's making me wonder what other issues are hiding in, well, plane sight on the Q400 just waiting for someone to trigger them
Fourthy mcfourth
Secondy McSecond.
ruclips.net/video/lnymRLHvmwA/видео.html
firsty McFirst
ruclips.net/video/lnymRLHvmwA/видео.html
The software failure draws comparison to the Therac 25. Different machinery but having your inputs involuntarily switched on you could be more deadly in the air than in the imaging ward. Seems like fixing it ought to be high on the 'to do' list.
@0:54... centre line.. centre line!!