And old trusty method of remembering a non-standard flap setting is throwing a empty cup over the flap handle. Works great!
Pilots Engaged in Small Talk Before Botched Jet Takeoff
- Thread starter derg
- Start date
And old trusty method of remembering a non-standard flap setting is throwing a empty cup over the flap handle. Works great!
Polar742
All the responsibility none of the authority
I see stuff that could happen to anyone. ONE mistake happened. Someone called for FLAPS 20 and FLAPS 8 were set. No one caught that ONE mistake. If someone had, it would have been one of those quick fixes that could have turned this into an "almost".
Two things that were pointed out: First the "Who's tired" comment. That right there should be a show-stopper. Second, the not pulling of the circuit breaker as called on the checklist.
What I see, really, is a lesson for Captains.
As a crewmember, especially as a Captain, it is up to US to recognize hazards and mistakes.
What hazards were presented?
1) An interruption of normal flight "flows".
Not so much in the modular process of readying the aircraft for each phase of operation, but in the grander sense of the flight. Push and start seemed normal, then they taxiied somewhere to park. To me, that is a red flag. As a matter of course, your routine for the flight was interrupted in the same manner as someone who is ground crew comes up and interrupts you as you are doing your panel setups.
2) Fatigue.
It was mentioned in conversation on the flight deck during duty.
3) Lack of transition from being "parked" back to "flying" mode.
We all know there are busy times that we need to focus and get the "killer" items done. One of those is readying the plane for takeoff. They continued the small talk when attention should be focused on getting the jet ready. I'm guessing the fatigue probably facilitated this.
4) When they are released to taxi, there was still jabber about non-flight stuff.
Quite honestly, I don't think the unrelated stuff, in and of itself, caused the issue. What the issue was seems to be the ongoing conversation while performing tasks in a non-routine operation. At that point, the Captain, but in reality either one of them, could have said "Hey, we're tired and we just taxiied and parked interrupting our flow...let's get our work s[tuff] done then get back to the 'vette".
4) Delay
The focus on making up time, in an airline pilot's mind, is a distraction that would detract from the performance.
I've been in those shoes and can think of instances where that could have just as easily been me.
Let's not crucify the crew. While it appears poor decisions were made (everyone does it from time to time, but we get lucky or catch it early enough), the bigger lesson should be one of recognizing these every day hazards in domestic line flying and equipping ourselves with the knowledge and tools to identify, evaluate and suppress these hazards.
Two things that were pointed out: First the "Who's tired" comment. That right there should be a show-stopper. Second, the not pulling of the circuit breaker as called on the checklist.
What I see, really, is a lesson for Captains.
As a crewmember, especially as a Captain, it is up to US to recognize hazards and mistakes.
What hazards were presented?
1) An interruption of normal flight "flows".
Not so much in the modular process of readying the aircraft for each phase of operation, but in the grander sense of the flight. Push and start seemed normal, then they taxiied somewhere to park. To me, that is a red flag. As a matter of course, your routine for the flight was interrupted in the same manner as someone who is ground crew comes up and interrupts you as you are doing your panel setups.
2) Fatigue.
It was mentioned in conversation on the flight deck during duty.
3) Lack of transition from being "parked" back to "flying" mode.
We all know there are busy times that we need to focus and get the "killer" items done. One of those is readying the plane for takeoff. They continued the small talk when attention should be focused on getting the jet ready. I'm guessing the fatigue probably facilitated this.
4) When they are released to taxi, there was still jabber about non-flight stuff.
Quite honestly, I don't think the unrelated stuff, in and of itself, caused the issue. What the issue was seems to be the ongoing conversation while performing tasks in a non-routine operation. At that point, the Captain, but in reality either one of them, could have said "Hey, we're tired and we just taxiied and parked interrupting our flow...let's get our work s[tuff] done then get back to the 'vette".
4) Delay
The focus on making up time, in an airline pilot's mind, is a distraction that would detract from the performance.
I've been in those shoes and can think of instances where that could have just as easily been me.
Let's not crucify the crew. While it appears poor decisions were made (everyone does it from time to time, but we get lucky or catch it early enough), the bigger lesson should be one of recognizing these every day hazards in domestic line flying and equipping ourselves with the knowledge and tools to identify, evaluate and suppress these hazards.
All that Martin and the fact they changed flaps while on the takeoff roll AND rejecting after V1 or so it seems.
I'm curious to see what the final investigation will show.
I want to make sure it doesn't seem like I think these guys were inept and it couldn't happen to me. If indeed they had a long duty day than that is obviously a huge factor.
Here is my question to those with more experience than me, at what point do you go well maybe they don't deserve just a training event and send them on their way? When does a blatant lack of judgement justify one losing their job? Ever?
I'm curious to see what the final investigation will show.
I want to make sure it doesn't seem like I think these guys were inept and it couldn't happen to me. If indeed they had a long duty day than that is obviously a huge factor.
Here is my question to those with more experience than me, at what point do you go well maybe they don't deserve just a training event and send them on their way? When does a blatant lack of judgement justify one losing their job? Ever?
ZapBrannigan
If it ain’t a Boeing, I’m not going. No choice.
People jump to the idea that training is the panacea and will fix anything. I differ in this thought process and base my opinion on adult learning theory (i'm a certified instructional designer). Training is performance based. i/e Ask the question: What task is the flight crew not performing (or not performing to a standard) that they will perform correctly at the conclusion of training?
In this case the answer would be, "they'll be quiet during sterile cockpit and pay attention to their job". Really? You can not train that behavior. They were fully aware of the requirement to conduct sterile cockpit. They were likely very aware of the requirements to be properly configured for takeoff. They were capable of doing those things. The standard was clear. They lacked the motivation to do it right every single time. Training can't fix that unfortunately.
Now what training CAN address is the Captain's failure to reject the takeoff in a timely manner, his failure to follow shutdown and/or evacuation procedures, CRM issues, and possibly his failure to consider the needs of passengers and crew prior to attending to his own issues.
This is a sad situation and could have happened to any one of us. Unfortunately, re-training won't address the core problem here imo. We're human. Humans get tired with early wakeups. Humans chit-chat occasionally during routine tasks.
There is no law or regulation that will address this. Professional flight discipline is something that requires intrinsic motivation. All the training in the world can't make that happen -- it comes from inside.
In this case the answer would be, "they'll be quiet during sterile cockpit and pay attention to their job". Really? You can not train that behavior. They were fully aware of the requirement to conduct sterile cockpit. They were likely very aware of the requirements to be properly configured for takeoff. They were capable of doing those things. The standard was clear. They lacked the motivation to do it right every single time. Training can't fix that unfortunately.
Now what training CAN address is the Captain's failure to reject the takeoff in a timely manner, his failure to follow shutdown and/or evacuation procedures, CRM issues, and possibly his failure to consider the needs of passengers and crew prior to attending to his own issues.
This is a sad situation and could have happened to any one of us. Unfortunately, re-training won't address the core problem here imo. We're human. Humans get tired with early wakeups. Humans chit-chat occasionally during routine tasks.
There is no law or regulation that will address this. Professional flight discipline is something that requires intrinsic motivation. All the training in the world can't make that happen -- it comes from inside.
Divine Wind
New Member
Unfortunately, that happens a lot more than people think. Many pilots have strong egos and believe they're the best and can never screw up. When they do screw up in a very big career ending way, they are stunned. The Captain here is obviously stunned into disbelief. The press article commented about his failure to properly respond to a question about a checklist by saying "Yeah, guess so". It's obvious to me he was in a state of mental shock.
What tells me a lot about his character is his forthrightedness about admitting to his mistakes. Some people here seem to advocate he should have applied "evasion and escape" procedures to dodge those questions, but I respect him for being honest about it. He screwed up and he admitted it.
One thing this accident is going to do is feed the fire to enforcing sterile cockpit through inflight monitoring.
Well said, Marine, and agreed 100%.
jtrain609
Antisocial Monster
Also, I don't know about the CRJ, but there are multiple documented situations where ERJ pilots have put out flaps 9 (normal) when they needed flaps 18 for whatever reason. They missed it, took off, and didn't realize that they had screwed up until the flying pilot made the call outs for a flaps 18 takeoff and they realized that they had flaps 9 out.
If you can an engine, you might be in a different situation, but with a two engine takeoff in the ERJ, folks have proven that on some runways, you won't hit anything if you takeoff with flaps 9.
Moral of the story? The abort may be more dangerous than flying the plane.
Your milage, of course, may vary...and this post is not a direct or indirect approval of such screw ups and I disclaim all liability for the opinions set forth.
If you can an engine, you might be in a different situation, but with a two engine takeoff in the ERJ, folks have proven that on some runways, you won't hit anything if you takeoff with flaps 9.
Moral of the story? The abort may be more dangerous than flying the plane.
Your milage, of course, may vary...and this post is not a direct or indirect approval of such screw ups and I disclaim all liability for the opinions set forth.
Divine Wind
New Member
True, but a tough call. If he'd hopped the EMAS but couldn't maintain flying speed, he'd be in a mountain.
In a similar situation, I'd hope I had the presence of mind to call for the abort in a timely manner and then execute full abort procedures with max braking and max reverse. This is given that I didn't catch the initial mistake. Part of the trap many pilots become trapped in is to compound an error with another error.
v1valarob
Well-Known Member
I have to disagree. He didnt fess up to anything. They quickly discussed what happened, and in the midst of all it forgot that the CVR was capturing it all.
At 16:14:27 - The FO says "What do you want me to do Tom?" This tells you right there that the Captain was in a state of shock, much like most would be, but in a state that seems more than you would hope someone who needs to be in command REAL quick during this type of situation. The FO seems to be in a less state of shock than his PIC.
Unfortunately I know quite a few Captains that probably would act the same way in this situation, or maybe even worse. You can really tell a good captain from the way they act on a go around after an unstable approach caused by weather. It really doesnt give you the warm and fuzzies as an FO when you have to ask your Captain "What would you like me to do?" then have them look at you confused.
I also find this interesting:
Captain
Total time: 9,525 hours
CL-65 time: 4,608
FO
Total time: 3,029 hours
CL-65 time: 1,981
This proves that even high time guys make mistakes.
ZapBrannigan
If it ain’t a Boeing, I’m not going. No choice.
Absolutely true. Moreso it proves that nomatter how good we THINK we are, it could happen to any one of us.
v1valarob
Well-Known Member
I should have worded it better as, it proves to the unknowing public that the higher time you have doesn't necessarily mean your god like. Those of us that know whats up, know that nothing beats experience, but that doesn't mean you dont make mistakes.
RightSeatGirl
KA'PLAH BITCHES!
No you were right, I was tired myself. The Dash T/O Warning horn will only go off with Flaps 0 degrees if the power levers are advanced to take off power. So with that clarification in mind it certainly could happen in the Dash. Though I will say that a flap setting greater than 5 degrees would only be necessary to satisfy the highly padded requirements of an FAA "paper mache" airplane.
Baronman
Well-Known Member
I would think that incorrectly setting flaps 9 instead of 18 would almost always allow for an adequate takeoff. Flaps 18 allow for a slower V1 thus shortening your accelerate stop distance and a higher initial climb angle (over obstacles). We're talking engine failure performance here folks...
If you would have insufficient pavement to accelerate to Flaps 9 VR, dropping V1 roughly 10kts for a flaps 18 would hardly provide much buffer. Likewise if you need a flaps 18 TO to clear an obstacle, you think there will be much buffer with only 9 degrees hanging out? In both cases I would think SE performance is what's at stake.
My guess is that with both engines running and flaps 9, this CRJ would have been airborne with no problems. Had they had an engine failure with flaps 9 speeds set at V1-10 kts, they probably would have gone off the end.
16:25:42
well okay i'm gonna tell you exactly what happened. Um well yeah we
were— we were flaps eight okay? Well uh # the data said flaps
twenty...and it was at eight so as we're going down the runway i kind of noticed that so i put it to twenty and then we got config flaps probably i'm
sure because they were movin'. So i just figured # okay i'll stop. You know
i got config flaps config spoilers so like # you know so i tried to stop and it
# went—yeah. So you know how— how am i gonna #— so cause
obviously they're gonna come and look at all this # right? They're gonna be
able to see it...yeah...no hold on a second. Hey everybody's fine right in
zmiller4
Well-Known Member
We have them as part of our taxi check, but due to the taxi check's length and how it requires the FO to be heads-down reading stuff we're now supposed to do the taxi check prior to moving the aircraft (at the CA's discretion we can do it on the taxi to relieve ramp congestion, etc). It's pretty nice for the FO to not have to worry about that stuff on the taxi out. I think every company has something in their SOP that has the potential to contribute to something like this (ours certainly does), and the really good captains find ways to minimize the risk.
I'd be interested to know what the TO roll would have been at flaps 8 and how the airplane would have behaved if they had rotated at 127 kts (that's probably 12-13kts slower than Vr for flaps 8). I've never done a flaps 8 TO in the 200 at less than about 4000' elevation so I don't know how long the takeoff roll would be, but at high elevations flaps 8 takeoffs are *really* long...long enough that 23 at CRW would seem really short.
I certainly won't bash these guys because it's honestly a mistake that anyone could make, and anyone who says otherwise is in my opinion dangerously overconfident.
BobDDuck
Island Bus Driver
How does that play out with single engine taxi procedures?
zmiller4
Well-Known Member
There's nothing on our taxi check that requires two engines running...we're not required to have a takeoff config OK status until the before takeoff check. If we're single-engine taxiing the FO starts #1 when the CA tells them to. Some guys will always go out on two, and some will go out on 1 even when they know it's a short taxi (very annoying). I'd much rather get the flaps, flight controls and takeoff data checked before leaving the gate, and I'd prefer a 2-engine taxi. I got seriously screwed by being heads-down once and it creeps me out a little (especially in ORD) unless the captain is on top of it and talks out their taxi route.
It's getting more like what SWA does (except they always seem to taxi out on both) where pretty much everything is done by the time they unhook the tug.
kellwolf
Piece of Trash
We USED to have the flaps as part of the taxi check, but then we moved it to the boxed itmes (which I guess is below the line at PSA) on the after start checklist. The main reason was one less thing for the FO to be heads down doing while the aircraft was moving. This incident kinda highlights another reason, though. You're not moving yet, so you're not distracted, so you can LOOK at the flap handle and LOOK at the EICAS to verify the correct flap setting instead of automatically saying "Flaps X degrees and indicating." We also pre-set v-speeds based on what our take off numbers are and verify them before leaving the gate. Just another net to catch something like this from slipping through.
I was sorta expecting some huge mandate to come down from the FAA after this one, but Zap is right. There's nothing training wise you can change to prevent something like this happening. It's an easy thing to miss, and any one of us can do it. The thing that baffles me is they tried to fix the problem ON THE ROLL rather than stop the airplane and fix it.
Same thing as Skywest for us on the SE taxi. We just have a separate checklist the FO runs to start the other engine, and the t/o config okay is checked on the before takeoff check.
I was sorta expecting some huge mandate to come down from the FAA after this one, but Zap is right. There's nothing training wise you can change to prevent something like this happening. It's an easy thing to miss, and any one of us can do it. The thing that baffles me is they tried to fix the problem ON THE ROLL rather than stop the airplane and fix it.
Same thing as Skywest for us on the SE taxi. We just have a separate checklist the FO runs to start the other engine, and the t/o config okay is checked on the before takeoff check.
deadstick
Well-Known Member
I just got this from the FAA regional office a couple of hours ago:
The procedure at PSA needs fixing. Just because "that's the way it's always been done" doesn't mean it's right.