Transair Flight 810 Crash NTSB report

[airway]

https://www.ntsb.gov/investigations/Pag ... FA174.aspx

What We Found
​We ​​determined the probable cause(s) of this accident to be: The flight crewmembers’ misidentification of the damaged engine (after leveling off the airplane and reducing thrust) and their use of only the damaged engine for thrust during the remainder of the flight, resulting in an unintentional descent and forced ditching in the Pacific Ocean. Contributing to the accident were the flight crew’s ineffective crew resource management, high workload, and stress.

From the NTSB final report:
The Engine Failure or Shutdown checklist defined three conditions that warranted the use of
that checklist: an engine failure, an engine flameout, or another checklist that directed an
engine shutdown. The checklist had 11 reference items, NONE OF WHICH WERE MEMORY ITEMS.

Does anyone know of any engine failure checklist that does not have some immediate memory items??? Especially if the engine failure was right after take off. Usually you just continue with your single engine departure (which you should have briefed), then IDENTIFY CONFIRM and SHUTDOWN. This should all be done by memory. Did they brief leveling off at 2000 ft if there was a engine failure? A partial power failure complicates things a bit though and we probably don't train for it enough.



.

[fish4life]

Lots of companies use QRC’s without memory items which IMO is a far superior way of doing it

[airway]

Lots of companies use QRC’s without memory items which IMO is a far superior way of doing it

OK, I've never seen one of those.

So if you have one of these QRH's and have have severe engine damage or fire right after T/O, what do you do? Continue with a normal 2 engine departure? When does the QRH come out?

[fish4life]

Lots of companies use QRC’s without memory items which IMO is a far superior way of doing it

OK, I've never seen one of those.

So if you have one of these QRH's and have have severe engine damage or fire right after T/O, what do you do? Continue with a normal 2 engine departure? When does the QRH come out?

Flying the aircraft is memory like flying the engine out speed is memory and then level off at the acceleration altitude (airport and aircraft dependent) and run the drill by reading off the checklist either it’s own quick reach doc or part of the normal checklist.

[cdnavater]

Lots of companies use QRC’s without memory items which IMO is a far superior way of doing it

OK, I've never seen one of those.

So if you have one of these QRH's and have have severe engine damage or fire right after T/O, what do you do? Continue with a normal 2 engine departure? When does the QRH come out?

For the RJ, severe damage, engine fire or flame out on departure is the same profile, you fly the aerodata(S/E performance profile) but don’t do anything until the aircraft is on profile and above 1000’ with flaps retracted, maximum continuous thrust is set for a flameout and call for the QRH. Severe damage/Fire is a QRC

[JL]

A good discussion paper on memory and checklists

https://www.easa.europa.eu/en/downloads/1250/en

[JL]

FAR 121.315 requires engine emergencies to have no memory items.


§ 121.315 Cockpit check procedure.

(a) Each certificate holder shall provide an approved cockpit check procedure for each type of aircraft.

(b) The approved procedures must include each item necessary for flight crewmembers to check for safety before starting engines, taking off, or landing, and in engine and systems emergencies. The procedures must be designed so that a flight crewmember will not need to rely upon his memory for items to be checked.

(c) The approved procedures must be readily usable in the cockpit of each aircraft and the flight crew shall follow them when operating the aircraft.

[co-joe]

...
Does anyone know of any engine failure checklist that does not have some immediate memory items??? Especially if the engine failure was right after take off. Usually you just continue with your single engine departure (which you should have briefed), then IDENTIFY CONFIRM and SHUTDOWN. This should all be done by memory. Did they brief leveling off at 2000 ft if there was a engine failure? A partial power failure complicates things a bit though and we probably don't train for it enough.

My company has no memory items for a simple engine failure, but engine fire, and engine severe damage have a couple immediate memory items. They're slow and methodical in a 737 though. You could light a smoke, take a drag, and then move one step at a time and still be fine (figuratively). Training with Boeing in Seattle, the sim instructor told us that several large airlines don't have any memory items on their 737's. They call for the QRC (quick reference checklist) and action items in a read and do method. I believe we have an airline in Canada that follows this philosophy.

[pelmet]

Quotes(in black) from a Flight International article based on NTSB information with the first line about engine failure identification.....

"The first officer, who was flying, replied “number two” – an apparent reference to the right-hand powerplant – and the captain also said, “number two”.

According to the quote above, the captain repeated what the F/O said(unknown if he based his reply on a separate analysis such as rudder pedal input/engine guages). Then according to the quote below, the copilot changed his mind and the captain did as well(unknown what further assessment was made by the captain before he changed his mind).

"According to the transcript, the captain asked the first officer to “read the gauges” to determine which “has the EGT” – the exhaust gas temperature – to which the first officer replied: “It looks like the number one.”The captain then responded, “Number one is gone?”, and the first officer responded: “[It’s] gone, yep…so we have number two.”

“So we have number two, OK,” the captain then remarked."

Post accident, the captain made this statement to the inquiry.....

"The captain told the inquiry that he thought the left-hand engine had the problem, at first, before changing his mind – based on the aircraft’s yaw and roll motion – and telling the first officer that he thought the right-hand engine was the one affected.

But during his testimony the captain referred to the first officer’s having told him that the number one engine, the left-hand powerplant, had failed.

The captain told investigators that the first officer, which whom he had flown several times, “never makes a mistake”, adding: “If [he] says number one is gone, then number one is gone.”

A bit of a conflict in statements but quite the trusting captain. Based on the CVR recording, it seems quite possible that the captain did change his mind based on what the F/O said, instead of analyzing the problem.

This reminds me of the Kegworth accident when it comes to failed engine identification. To quote the report.....

"The first officer also said that he monitored the engine instruments and, when asked by the commander which engine was causing the trouble, he said 'IT'S THE LE ... IT'S THE RIGHT ONE.', to which the commander responded by saying 'OKAY, THROTTLE IT BACK'."

Once again, no detail on what analysis the Transair captain did, but it does give one the feeling that he may have relied on what the copilot said instead of confirming himself(captain was flying). One really should take extra time to identify a partial engine failure, if time permits. the consequences of a mis-identification can be catastrophic. In addition, a partial failure may not be obvious after thrust has been reduced. And there is no extra drag like a turboprop, so time is not usually as critical. One needs to confirm which engine failed but should also confirm that the other pilot has correctly identified the bad engine.

[airway]

Once again, no detail on what analysis the Transair captain did, but it does give one the feeling that he may have relied on what the copilot said instead of confirming himself(captain was flying). One really should take extra time to identify a partial engine failure, if time permits. the consequences of a mis-identification can be catastrophic. In addition, a partial failure may not be obvious after thrust has been reduced. And there is no extra drag like a turboprop, so time is not usually as critical. One needs to confirm which engine failed but should also confirm that the other pilot has correctly identified the bad engine.[/i]

Yes, they both correctly identified the affected engine right away with the high power setting after take off, but later changed their mind when both power levers were at or near flight idle. After they made that decision, it looks like they didn't even think about adding power to the good engine.

Something to think about if you have an engine failure, say in the descent at a low power setting. You might want to level off and add power before you decide which engine has a problem.



.

[cjp]

Lots of companies use QRC’s without memory items which IMO is a far superior way of doing it

OK, I've never seen one of those.

So if you have one of these QRH's and have have severe engine damage or fire right after T/O, what do you do? Continue with a normal 2 engine departure? When does the QRH come out?

Climb away at single engine departure speed to specified altitude (depending on company and Captain - 400-1000' AGL), accelerate, and clean up the aircraft. After clean up, memory items and QRH. While doing this, also advising ATC of emergency with mayday.

[pelmet]

Once again, no detail on what analysis the Transair captain did, but it does give one the feeling that he may have relied on what the copilot said instead of confirming himself(captain was flying). One really should take extra time to identify a partial engine failure, if time permits. the consequences of a mis-identification can be catastrophic. In addition, a partial failure may not be obvious after thrust has been reduced. And there is no extra drag like a turboprop, so time is not usually as critical. One needs to confirm which engine failed but should also confirm that the other pilot has correctly identified the bad engine.[/i]

Yes, they both correctly identified the affected engine right away with the high power setting after take off, but later changed their mind when both power levers were at or near flight idle. After they made that decision, it looks like they didn't even think about adding power to the good engine.

Something to think about if you have an engine failure, say in the descent at a low power setting. You might want to level off and add power before you decide which engine has a problem.

I get the feeling that the captain just correctly repeated and believed what the copilot was saying in terms of failed engine identification as opposed to correct identification by himself. Granted, in some situations, you may have to rely on the other person, but especially if there has been a change, I suggest more careful analysis before a shutdown, if time permits.

[digits_]

Something to think about if you have an engine failure, say in the descent at a low power setting. You might want to level off and add power before you decide which engine has a problem.

That's a great point. I've probably done a hundred engine failures in sims by now, and this scenario was never part of it. Lots of V1 cuts and engine failures in cruise, but never during a descend.

[NotDirty!]

If only there was a way for the airplane to detect that there was some sort of engine failure, and display the appropriate “L/R ENGINE FAIL” message on some sort of crew alerting system… better still, what if that same screen went on to display the appropriate checklist!!

[TeePeeCreeper]

If only there was a way for the airplane to detect that there was some sort of engine failure, and display the appropriate “L/R ENGINE FAIL” message on some sort of crew alerting system… better still, what if that same screen went on to display the appropriate checklist!!

Now we need a friggen light? Yet another annunciator?

Whatever happened to “dead foot=dead engine” followed by “hey dear pilot monitoring! Can you confirm this quickly?”.

Jesus, I know human factors are at play but the dumbing down of aviation is doing just fine…

TPC

[DanWEC]

I'd say that Mr Clean is practicing a bit of sarcasm. The bus will say Eng 1/2 fail on the ECAM, along with associated actions. Don't know how it's actioned on the 73 though. But anyways, you should generally not do that much, that quickly, in a jet unless absolutely necessary. Fly the plane, take a breath while putting on your hat, then get to work.

[J31]

An engine failure in the Boeing 737 does not require immediate actions other than flying the airplane. There is no propellor causing drag and nothing else requires immediate action.

Even an engine fire requires that the aircraft be under control, stable and climbing before actioning any engine drill. Then determine the memory drill or the checklist that fits the problem.

Boeing and many airlines use a Quick Reference Handbook (QRH). Other Boeing operators use a Quick Reference Checklist (QRC). Both can have memory actions or be read and do as the operator decides. I have used both with and without memory actions. I prefer one stop shopping in a read and do QRH.

In this case the engine was damaged but still developing thrust. It was not an engine failure and shutdown drill! It was a severe damage drill! But they did not do either drill, and never identified the damaged engine.

It is easy to armchair quarterback this crash looking at the details after the fact, and these pilots were tired, operating late at night, with hot running engines, in a poorly maintained 737.

[pelmet]

If only there was a way for the airplane to detect that there was some sort of engine failure, and display the appropriate “L/R ENGINE FAIL” message on some sort of crew alerting system… better still, what if that same screen went on to display the appropriate checklist!!

Caught a fish pretty quick with that one

Not sure all scenarios are covered though with the ENGINE FAIL detection system.

[Donald]

Something to think about if you have an engine failure, say in the descent at a low power setting. You might want to level off and add power before you decide which engine has a problem.

That's a great point. I've probably done a hundred engine failures in sims by now, and this scenario was never part of it. Lots of V1 cuts and engine failures in cruise, but never during a descend.

Many years ago, during training on the Jurassic, the instructors would give you a dual engine failure in a descent. It often got misdiagnosed as a loss of both engine driven generators.

[Crewbunk]

Many years ago, during training on the Jurassic, the instructors would give you a dual engine failure in a descent. It often got misdiagnosed as a loss of both engine driven generators.

The one I always liked was a dual engine failure on climb out due to centre tank fuel contamination. Lose both engines/generators from centre fuel, then gravity feed the mains, engines fire back up. Generators fire back up, centre pumps start working again, lose both engines/generators again. Gravity feed the mains, engines/generators start again …

This cycle will continue till you figure it out!

(Instructors were cruel in those days)

[goleafsgo]

Lots of companies use QRC’s without memory items which IMO is a far superior way of doing it

OK, I've never seen one of those.

So if you have one of these QRH's and have have severe engine damage or fire right after T/O, what do you do? Continue with a normal 2 engine departure? When does the QRH come out?

The E175 is just a checklist for engine failure and memory items for engine fire. Even with a fire at v1 the memory items don’t happen until after the flaps are retracted above 1000’

[pelmet]

Something to think about if you have an engine failure, say in the descent at a low power setting. You might want to level off and add power before you decide which engine has a problem.

That's a great point. I've probably done a hundred engine failures in sims by now, and this scenario was never part of it. Lots of V1 cuts and engine failures in cruise, but never during a descend.

Many years ago, during training on the Jurassic, the instructors would give you a dual engine failure in a descent. It often got misdiagnosed as a loss of both engine driven generators.

That is frequently the first thing noticed for an engine failure at low power.....generator issue.

[Donald]

Many years ago, during training on the Jurassic, the instructors would give you a dual engine failure in a descent. It often got misdiagnosed as a loss of both engine driven generators.

The one I always liked was a dual engine failure on climb out due to centre tank fuel contamination. Lose both engines/generators from centre fuel, then gravity feed the mains, engines fire back up. Generators fire back up, centre pumps start working again, lose both engines/generators again. Gravity feed the mains, engines/generators start again …

This cycle will continue till you figure it out!

(Instructors were cruel in those days)

Sadistic!!

I love it, haha.

[ant_321]

Many years ago, during training on the Jurassic, the instructors would give you a dual engine failure in a descent. It often got misdiagnosed as a loss of both engine driven generators.

The one I always liked was a dual engine failure on climb out due to centre tank fuel contamination. Lose both engines/generators from centre fuel, then gravity feed the mains, engines fire back up. Generators fire back up, centre pumps start working again, lose both engines/generators again. Gravity feed the mains, engines/generators start again …

This cycle will continue till you figure it out!

(Instructors were cruel in those days)

I know what I’m doing next time I get a know it all in the sim

[CaptDukeNukem]

Many years ago, during training on the Jurassic, the instructors would give you a dual engine failure in a descent. It often got misdiagnosed as a loss of both engine driven generators.

The one I always liked was a dual engine failure on climb out due to centre tank fuel contamination. Lose both engines/generators from centre fuel, then gravity feed the mains, engines fire back up. Generators fire back up, centre pumps start working again, lose both engines/generators again. Gravity feed the mains, engines/generators start again …

This cycle will continue till you figure it out!

(Instructors were cruel in those days)

Sadistic!!

I love it, haha.

Pardon my lack of other types of airplane knowledge, but this sounds incredibly good simulated fun. What aircraft is this on?