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Paul_Smith

The perils of flying a computer.

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Modern airliners are programmed for every stage of long haul flights before they leave the ground. I have, on more then one occasion, handed over control during the take off roll and had nothing to do until the landing flare except maybe raise and lower the landing gear. And, like most people, I have sometimes messed up when configuring the navigation system. If you ever wondered what the consequences would be in real life, the linked article describes what can go wrong when flying a plane becomes programming a computer. The initial mistake was both small and easily made and the follow up mistakes were avoidable and just compounded the problem. Other then pride, no one was hurt.

 

[Mods: The web site is a UK based IT news site, but feel free to move/remove this thread as it is more general aviation awareness then PMDG product specific, but I thought the PMDG users would enjoy it. ] 

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this sounds more like a breakdown of CRM and cross checking between crew members. I hate to say it, but these kind of things are happening more and more with Asian carriers.

 

I had the luxury of teaching zero to hero Asian students. very few could speak English and I wouldn't trust any that I came in contact with with me or my family.

 

That may sound harsh but almost all the students could not think outside an SOP and/or fix their mistakes if they made any which put them in a situation that wasn't "normal." The almost all exhibited invincible attitudes and they really didn't understand the responsibility of flying.

 

having said that, I'm not saying anything of this crew, however, as I said before, these types of things are starting to happen more often and with my experience, I can see why. I hope I'm wrong.

 

I'm not saying that this crew was Asian and there heritage is the problem. im also not saying asian pilots are horrible. in fact i know quite a few who are amazing pilots. I'm saying that Asian based carriers are to blame because of some of their hiring practices as well as an obvious lack of training.

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I think it's well-known, or it used to be, that they have the practice of hiring ex-military pilots who have a different way of thinking and no-questions-asked when it comes to questioning the pilot's actions.

An American example way back when,  was the Air Florida crash back in the 90's - The co-pilot did not question the actions of the pilot. There have been recent accidents in Taiwan with the ATR crash where the pilot switched off the wrong engine, and lets not forget the One2Go crash in Phucket.

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I think it's well-known, or it used to be, that they have the practice of hiring ex-military pilots who have a different way of thinking and no-questions-asked when it comes to questioning the pilot's actions.

An American example way back when, was the Air Florida crash back in the 90's - The co-pilot did not question the actions of the pilot. There have been recent accidents in Taiwan with the ATR crash where the pilot switched off the wrong engine, and lets not forget the One2Go crash in Phucket.

not questioning someone of higher position is a cultural thing there that extends far beyond military vs. civilians and way beyond the flight deck.

 

As for the air florid a incident, the FO did actually speak up saying he thought something wasn't right. The CA didn't listen and the FO should have been much more assertive.

 

Even with the evolution of CRM here in the states, I could see the same thing happening now that happened with air Florida in terms of communication. especially with new regional FOs. it's hard to find your voice when you're new in an airline environment.

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In the all-time worst crash, KLM and Pan Am 747s on Tenerife, the KLM co-pilot was unsure whether their 747 had been cleared for takeoff in very foggy conditions (it hadn't), but was not assertive enough toward a very senior captain.

 

I am very uncomfortable with generalizations about Asian pilots.  There are plenty of examples of dumb mistakes by pilots of many different cultures and nationalities. In the Air Asia incident, the A330 systems programmers, who may well have been French or German, deserve some blame for not including a warning in the event of a discrepancy between GPS position and entered position from the first software version.  People make mistakes. 

 

Mike

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In the all-time worst crash, KLM and Pan Am 747s on Tenerife, the KLM co-pilot was unsure whether their 747 had been cleared for takeoff in very foggy conditions (it hadn't), but was not assertive enough toward a very senior captain.

 

I am very uncomfortable with generalizations about Asian pilots.  There are plenty of examples of dumb mistakes by pilots of many different cultures and nationalities. In the Air Asia incident, the A330 systems programmers, who may well have been French or German, deserve some blame for not including a warning in the event of a discrepancy between GPS position and entered position from the first software version.  People make mistakes. 

 

Mike

I'm not saying all Asian pilots are horrible pilots. I'm only drawing from my own experiences. that is all.

 

people make mistakes? entering a coordinate wrong in the manner the pilot did is unacceptable.

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I'm not saying all Asian pilots are horrible pilots. I'm only drawing from my own experiences. that is all.

 

people make mistakes? entering a coordinate wrong in the manner the pilot did is unacceptable.

Initially you did generalise to all Asian crews. It's good you are qualifying that now.

 

In that case all mistakes are unforgivable. The problem here was the entry was not checked. Surely you would forgive the pilot if the mistake was found in a cross check and corrected?

 

In this case nobody died. Hopefully both crew members, and the operator, learned from the experience. Far better to recognise an error and overcome it safely, as they did, than sweep it under the carpet and risk making the same mistake again. The crew made a mistake and they corrected it. Is that unforgivable?

 

It must be said it is rather easy to upset the Airbus IRS position with a single entry. It does ask you to confirm and the FCOM is very clear about the risk. But I suppose that during preflight they were less concerned about the consequences. Do the same thing in flight and you are in a world of trouble. Easier to correct on ground, as long as you are aware something is wrong....

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The crew made a mistake and they corrected it. Is that unforgivable?

 

You raise a really good angle on this kind of issue, which goes way beyond aviation to pretty much any safety-related field. From a management perspective, if you want people to do their jobs right, you can't really come down on people for self-reporting mistakes that they recovered from.

 

I'm a CDL trainer and one thing all of my trainees hear from me is that doing your job safely is not about being perfect, but rather about being able to quickly recognize and recover from mistakes when you make them - and you WILL make them. Avoiding problems is great, but it's not always possible.  The safety gods don't care if you're on day 1 or year 40 - no matter who you are, if something happens you have to react properly.

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I'm not saying all Asian pilots are horrible pilots. I'm only drawing from my own experiences. that is all.

 

people make mistakes? entering a coordinate wrong in the manner the pilot did is unacceptable.

 

It's absolutely unacceptable.  You go to the wrong spot on a PPL checkride, you fail it.  The fact that this was entered so MASSIVELY incorrectly and obviously never checked (because you'd see it on the ND) speaks to some pretty lazy procedures.  I enter flight plans on a G1000 all the time, and I always check to make sure they make sense.

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Initially you did generalise to all Asian crews. It's good you are qualifying that now.

In that case all mistakes are unforgivable. The problem here was the entry was not checked. Surely you would forgive the pilot if the mistake was found in a cross check and corrected?

In this case nobody died. Hopefully both crew members, and the operator, learned from the experience. Far better to recognise an error and overcome it safely, as they did, than sweep it under the carpet and risk making the same mistake again. The crew made a mistake and they corrected it. Is that unforgivable?

It must be said it is rather easy to upset the Airbus IRS position with a single entry. It does ask you to confirm and the FCOM is very clear about the risk. But I suppose that during preflight they were less concerned about the consequences. Do the same thing in flight and you are in a world of trouble. Easier to correct on ground, as long as you are aware something is wrong....

they corrected it way too late. This type of screw up is what I'm saying when there are too many Asian carriers showing up in the news for making mistakes of this magnitude. Their skill set isn't there. They should have cross checked this but they didn't. they had plenty of chances to rectify this before they got in the air. they didn't.

 

this is a perfect example of gross negligence from the crew.

 

Like I said, I'm not saying all Asians are bad pilots. I am saying asian carriers are starting to kill people and have these types of blunders more often. That's not good.

 

saying they corrected this mistake in a good way is the equivalent of saying an airplane took off without enough fuel but turned back when they figured out the problem. Absolutely not, in the above fake scenario, the crew had ample opportunities to fix said fuel issue before it ever left the ground.

You raise a really good angle on this kind of issue, which goes way beyond aviation to pretty much any safety-related field. From a management perspective, if you want people to do their jobs right, you can't really come down on people for self-reporting mistakes that they recovered from.

 

I'm a CDL trainer and one thing all of my trainees hear from me is that doing your job safely is not about being perfect, but rather about being able to quickly recognize and recover from mistakes when you make them - and you WILL make them. Avoiding problems is great, but it's not always possible.  The safety gods don't care if you're on day 1 or year 40 - no matter who you are, if something happens you have to react properly.

apples to oranges really

Some mistakes just can't happen. Plain and simple. Setting up the nav equipment so poorly and not cross checking it and then getting into the air to find out you screwed up and then have to divert because of it is unacceptable. should they get fired? no. however, they need to get serious extra training in basic CRM procedures. What could have happened if they didn't realize their mistake until they were literally in the middle of nowhere with nowhere to divert?

 

this isn't something simple like missing a crossing restriction by 500 ft. It's OK to make mistakes we are human. When we bring other people's lives into danger or seriously risk others lives because of our mistakes, that's a completely different matter.

 

A gate return is one thing. An air return however, is completely different.

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One thing that keeps returning as a surprise is and I quote "... handed over control during the take off roll and had nothing to do until the landing flare except maybe raise and lower the landing gear."

 

Who on earth ever told that if you give control to a computer you have to do "nothing" anymore ? even boeing states that the autopilot and all of its FMS functions are there to support the pilot, bringing automation into the flying so that some tasks are easier to be managed...

 

Now, I am an IT guy and I can tell you that if there is one thing you should do, verify the computer (autopilot) it is responding well to your input. I don't think you do nothing, I do think your "managing" the aircraft thru automation and verification, that can also be very busy on departure / arrival.

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Some mistakes just can't happen. Plain and simple. Setting up the nav equipment so poorly and not cross checking it and then getting into the air to find out you screwed up and then have to divert because of it is unacceptable. should they get fired? no. however, they need to get serious extra training in basic CRM procedures. What could have happened if they didn't realize their mistake until they were literally in the middle of nowhere with nowhere to divert?

Cant remember the flight number but   similar  situation  but  with more  tragic  results.   pilots  were  flying  and  preparing  to land at a  airport  they dialled  the wrong   vor or  ndb  freq for  a landing  atc  told  them to report  when  they passed  the beacon. in the confusion  the plane  crossed  over  the wrong valley  for  the landing  and the  result  was  they crashed.Some  one  will know  the flight details

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Cant remember the flight number but   similar  situation  but  with more  tragic  results.   pilots  were  flying  and  preparing  to land at a  airport  they dialled  the wrong   vor or  ndb  freq for  a landing  atc  told  them to report  when  they passed  the beacon. in the confusion  the plane  crossed  over  the wrong valley  for  the landing  and the  result  was  they crashed.Some  one  will know  the flight details

 

Sounds like an incident in South America. Aircraft descending westbound into Santiago in Chile, misjudged position and flew into the last part of the Andes, which they thought they had already passed. That was partly due to some confusion about FMC selections and inadequate cross checking.

 

The topic also reminded me of another incident more than 30 years ago, in the days before GPS.

 

A Korean Air 747 had set up the INS incorrectly for a trans polar flight and crossed into a very sensitive part of Russian airspace. They did not respond to Russian radio warnings, thinking they were somewhere else, many miles from Russia. The 747 was shot down by a ground to air missile. Everyone was killed. Investigation showed wrong start point coordinates were set.

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Well that was not the reaction I was expecting.

 

We have had suggestions that Asians cant fly that were barely challenged and hints that the death penalty might be the appropriate for procedural errors. The common theme being that others were at fault and must be blamed. You will forgive me for stating that I hope none of you are commercial pilots. What I was hoping for was the recognition that we all make mistakes and it is up to us to expect them, recognize them and correct them. If you want to identify fault or cause, it should only be so that procedures can be improved to reduce repetition. Leave the blame for lawyers and ambulance chasers.

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Do airbus pilots really need to enter coordinates manually? If that's true then the problem is FMGS being not automated enough.

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Well that was not the reaction I was expecting.

 

We have had suggestions that Asians cant fly that were barely challenged and hints that the death penalty might be the appropriate for procedural errors. The common theme being that others were at fault and must be blamed. You will forgive me for stating that I hope none of you are commercial pilots. What I was hoping for was the recognition that we all make mistakes and it is up to us to expect them, recognize them and correct them. If you want to identify fault or cause, it should only be so that procedures can be improved to reduce repetition. Leave the blame for lawyers and ambulance chasers.

look at my signature, that will tell you enough about my credentials.

 

having said that, no one ever said mistakes are only punishable by death. however, this gross negligence in cross checking and literally not being able to recognize such a gross error is a big issue. that's just bad piloting. Plain and simple. as I said before, if they would have caught this mistake on the ground, I would have a completely different outlook on it. more so to the tune of fill out an ASAP and be done with it.

 

that didn't happen though. they never recognized the error until they where in cruise. It's a mistake that is can be forgiven for sure. however, it's unacceptable that they let it get that far.

 

like I said, a gate return is nothing compared to an air return.

 

look ant other accidents and I guarantee you that all accidents can be "forgiven," however that doesn't mean they should have ever happened in the first place. Comair 5191 comes to mind...

 

the crew made antecedents honest mistake and they lined up on the wrong runway. they never crosschecked it and look what happened. it's so sad that people lost their lives. Knowing what it's like to fly that early and be under time constraints like that, I most definitely

forgive the crew. however, it should have never never happened.

 

don't come on here saying that you hope people aren't commercial pilots just because they have a different opinion than you do. they may know more about what they are talking about and about the situation than you do.

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I'm just wondering whether, when the pilot input the coordinates, he was relying on the computer to inform him if he had made a mistake. Put another way, did the pilot interpret the absence of any obvious warning of error to be a confirmation that his entry was correct?

 

That goes beyond mere CRM and would point towards areas of improvement in crew and computer interaction.

 

I don't have any experience in Airbus automated flight systems, but I once made a similar mistake when setting up the FMC on the 737NGX and the FMC returned a message to alert me to the discrepancy between where I told the plane it was and where its onboard GPS system indicated it really was. I quickly rectified the error. I would be surprised if the Airbus systems don't have a similar function. If it does, then it would be worth looking at the way in which it alerts the crew of an input error. If it doesn't have a similar warning system in place, well ...

 

I would go beyond that and suggest that when it comes to designing aircraft flight computers, it would be worth drawing on the experience of cognitive scientists. It has only been over the last forty years that psychology has started to piece together how badly even a fully functional brain operates, and the obvious risks that this poses for our behaviour. And to put that into perspective, the 747 has been flying for longer than we have understood the way in which our minds find creative ways to malfunction in the name of evolutionary expedience.

 

I would say that with SOP's and experience comes certainty, and with certainty comes a reluctance to question our actions, this is a scientifically proven fact. And though obviously, most pilots get this right most of the time, a recognition of the limitations of the human mind, and the accompanying penchant, for making seemingly incomprehensible mistakes, would help us to design systems that take into consideration very real human limitations like seeing what we want to see, even when what we claim to have seen is not what was actually there, such as one number in a long sequence being out of place.

 

There is no amount of training in procedures or experience in flying which can counteract the mind's tendency for taking short cuts with devastating consequences, but a recognition of this fact about the mind and incorporating it into how flight computers interact with pilots can help us design systems which provide a check on mental inefficiency.

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Do airbus pilots really need to enter coordinates manually? If that's true then the problem is FMGS being not automated enough.

No, the IRS takes it's initial alignment position from the departure airport. But then the crew adjust this lat/long for the exact gate position. They can use slew keys but in this case the Captain entered the data from the keypad, incorrectly. The aircraft didn't have a software mod that checks for sensible inputs, but since the incident all Air Asia planes have been updated.

 

You do have to manually enter the alignment position in a Boeing, though of course you can copy last position or current GPS position to the scratchpad to help you. But for precise alignment you need to enter the gate position.

 

 

 

that didn't happen though. they never recognized the error until they where in cruise. It's a mistake that is can be forgiven for sure. however, it's unacceptable that they let it get that far.

 

like I said, a gate return is nothing compared to an air return.

According to the linked report they recognised the problem as soon as the aircraft took off.

 

A gate return is less of an issue than an air return, but a safe air return is still far better than the alternative of attempting to continue unsafely.

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No, the IRS takes it's initial alignment position from the departure airport. But then the crew adjust this lat/long for the exact gate position. They can use slew keys but in this case the Captain entered the data from the keypad, incorrectly. The aircraft didn't have a software mod that checks for sensible inputs, but since the incident all Air Asia planes have been updated.

 

You do have to manually enter the alignment position in a Boeing, though of course you can copy last position or current GPS position to the scratchpad to help you. But for precise alignment you need to enter the gate position.

 

 

 

According to the linked report they recognised the problem as soon as the aircraft took off.

 

A gate return is less of an issue than an air return, but a safe air return is still far better than the alternative of attempting to continue unsafely.

I applaud you for giving the crew the benefit of the doubt. However, the article also states that they didn't crosschecked it and that the airplane was trying to tell them something; but they didn't bother to investigate. That right there is the problem. they didn't do their due diligence to ensure the outcome of the flight would not be in question.

 

having said that, I agree with you that a safe air return is better than just continuing. Although, this air return should have never had to happen in the first place.

 

This incident will be a great tool for annual recurrent training at said carrier. Other than that, I don't see anything else coming of this. The crew shouldn't be terminated, just some extra training in CRM.

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I applaud you for giving the crew the benefit of the doubt. However, the article also states that they didn't crosschecked it and that the airplane was trying to tell them something; but they didn't bother to investigate. That right there is the problem. they didn't do their due diligence to ensure the outcome of the flight would not be in question.

 

having said that, I agree with you that a safe air return is better than just continuing. Although, this air return should have never had to happen in the first place.

 

This incident will be a great tool for annual recurrent training at said carrier. Other than that, I don't see anything else coming of this.

Where did I give the crew the benefit of the doubt? I was just correcting what you said about the crew getting to cruise before they noticed the problem. Of course the error should have been caught on the ground. Has anyone said otherwise?

 

The crew shouldn't be terminated, just some extra training in CRM.

Surely an unacceptable error requires more action, compared to an acceptable error?

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Where did I give the crew the benefit of the doubt? I was just correcting what you said about the crew getting to cruise before they noticed the problem. Of course the error should have been caught on the ground. Has anyone said otherwise?

 

 

Surely an unacceptable error requires more action, compared to an acceptable error?

Why Bait me in this fashion? what's the point?

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No, the IRS takes it's initial alignment position from the departure airport. But then the crew adjust this lat/long for the exact gate position. They can use slew keys but in this case the Captain entered the data from the keypad, incorrectly. The aircraft didn't have a software mod that checks for sensible inputs, but since the incident all Air Asia planes have been updated.

 

You do have to manually enter the alignment position in a Boeing, though of course you can copy last position or current GPS position to the scratchpad to help you. But for precise alignment you need to enter the gate position.

 

 

According to the linked report they recognised the problem as soon as the aircraft took off.

 

A gate return is less of an issue than an air return, but a safe air return is still far better than the alternative of attempting to continue unsafely.

Thanks, that makes sense now. I only knew that on 737 you can enter the airport and gate number to get the position from navigation database. 

 

It's very surprising that none of the pilots noticed the issue on the ground. With the wrong input I assume the routes won't even show up on ND, unless it's in plan mode.

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