DHL Vilnius crash interim report

NovemberEcho

NovemberEcho

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Highlights:

DHL crash in Vilnius: interim report

[https://sia.lrv.lt/public/canonical...0 Boeing 737-400SF EC-MFE Interim Report.pdf)



* No signs of any intentional damage/terrorism
* Voice recorders showed the crew only conversed on job matters
* The crew struggled to maintain radio frequency
* On approach to Vilnius airport hydraulic system B switched to off position; the switches were found in off position
* The flaps at that moment were at 0 degrees
* Anti-ice was off – the crew thought it was on
* Autopilot B switched off, co-pilot took over manually
* No signs of technical issues before the impact, test results pending
* No signs of fire before the impact
 
Just kinda looking at:

a) the timing of discussion about anti-ice and the Hyd B pressure drop, and
b) the location & design of the switches on the overhead panel,

I wonder if the crew inadvertently closed the hydraulic EDP valve when they meant to select/verify engine the anti-ice switch position. However the throw direction for ON is the same for both systems. 🤷‍♂️
 
Minuteman said:
Just kinda looking at:

a) the timing of discussion about anti-ice and the Hyd B pressure drop, and
b) the location & design of the switches on the overhead panel,

I wonder if the crew inadvertently closed the hydraulic EDP valve when they meant to select/verify engine the anti-ice switch position. However the throw direction for ON is the same for both systems. 🤷‍♂️
Click to expand...
That's what happened. Turned off B system instead of turning on EAI. Apparently it's a fairly common error due to location of the switches. Low time F/O and cluster of comm frequency errors. What I can't get is how they missed the flaps not extending when commanded. That's pretty bad. Juan Brown's did a video that's goes over the FDR and CVR.
View: https://www.youtube.com/watch?v=WLWcNoSqwvY
 
DE727UPS said:
That's what happened. Turned off B system instead of turning on EAI. Apparently it's a fairly common error due to location of the switches. Low time F/O and cluster of comm frequency errors. What I can't get is how they missed the flaps not extending when commanded. That's pretty bad. Juan Brown's did a video that's goes over the FDR and CVR.
View: https://www.youtube.com/watch?v=WLWcNoSqwvY
Click to expand...

Yep, a mistake a lot of us have made. You would hope though that as soon as the master caution lights up one would realize what’s going on, but then again at night and in the midst of comm frequency confusion and suddenly back to hand flying plus the absolutely • crew alerting setup I can see it happening the way it did.
 
derg said:
Read the label, flip/press it.

I had more people turn off the generators and the ground power when they’re doing a shutdown flow quickly.
Click to expand...
I still have to think about my flows when I fly. Even after two years in the plane. It's tough when you are in the seat maybe once a month.
 
CoffeeIcePapers said:
At my last stop, we had a CA run an ECAM for an inop while the FO was in the lav. You know what happened next.
Click to expand...
I don't.
1743683580685.gif
 
derg said:
Read the label, flip/press it.

I had more people turn off the generators and the ground power when they’re doing a shutdown flow quickly.
Click to expand...
The cowl anti ice and Hyd are really easy to crisscross. Especially at night. Ergonomics not being a thing in 1967, you know.

I've never done it but I've been cautioned repeatedly when newer, and I've stopped other people during an attempt.
 
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