TransAsia Airways plane carrying more than 50 people crashes

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Canoehead
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Canoehead »

xsbank wrote:So Canoe, you're telling me that nobody 'does' the engine fail drill until you get back in the sim in 6 months? That makes me feel all warm and fuzzy. No wonder they fall out of the air.
Hi xs. I'm not meaning to sound flippant when I tell you that, but it is true. It was removed from our operation after lots of discussion and risk assessment. It wasn't simply thrown out, but a more thorough briefing with cabin crew takes place, where selected emergencies are discussed.
For the record, haven't seen any of our flights "fall out of the air" yet. Closest to it was the unfortunate crash at Dryden in 1989. No amount of drill rehearsal would have helped that day.
Liquid Charlie wrote:
I have mixed feelings how much this helps it's the same with scripted crew briefings -- people tend to spew them out from memory at such a high rate that no one pays attention anyway -- as far as drills -- you have to know them and if you are depending on crew briefings to keep them in your memory -- come on -- it's too late - it's fuked already -- why would anyone feather the wrong engine -- by being in a hurry and not waiting for confirmation -- I always fall back on the old phrase -- "fly the fuking aircraft" first and work efficiently through your drills and check lists -- this might shock a few here but from my point of view the guy in the left seat was low time (in the real world around 4000 hrs is low time) -- as pointed out he could be upgrading -- sadly if he had done nothing else except fly the aircraft and not touched anything this accident likely would not of happened --

From an old grey haired gentleman who has several engine failures and many shut downs -- slow down -- confirm everything and work like a team and fall back on what you learned in the sim -- a food for thought -- by far most of my failures and shut downs have been turbine and jet engines -- pay attention single engine drivers -- stay sharp
You hit the nail on the head LC. Regarding drills for large turboprops like the ATR, there are several different possible malfunctions and required actions. The time afforded for reviewing all the possible scenarios just isn't there; and it became simple rote verbiage to satisfy a requirement. It's expected that you know your vital/memory actions, just like it's expected that you know your airplane. That's what we get paid to do. What you say about slowing down: amen. I can say without hesitation that the best executed drills I see in the sim are from those who are methodical and deliberate about what they are doing. I'm not passing judgement on this crew (yet), but just stating my observation related to the latest news from Taiwan.

Regarding experience, I agree completely. They are touted as "experienced", but really they aren't. Especially if you do the math- virtually all their time is in the ATR. There are experiences gained from flying several types enroute to 4, 5 or 8000 hours. That's a whole other debate, but one I am a firm believer in. As a 10,000 hour pilot, with about half that in both seats of the DH8 family of airplanes, I consider myself on the "low side of experienced"; mainly because I've had generally a fairly benign flight career to now (no engine failures... yes I know!, no major smoke events etc). I've learned lots flying with guys who have had these things happen over their many more flying hours than mine.

Your sage advice is to fly the airplane first. Absolutely. My advice to conducting a drill (besides slow it down), is "Say-Pause-Do". Say (clearly/loudly) what the action is you're about to do, Pause to allow the other pilot (or perhaps Jumpseat occupant!) to interject if they disagree, then do the action. It's not a race.

Anyways, if this was indeed a case of incorrect engine being shutdown, that's a costly and totally preventable mistake.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Eric Janson »

There is an increasing problem where "training" has become a box ticking exercise. The same scenarios are run over and over again without any variation. They are all published beforehand so a trainee knows exactly what is coming.

Example:- Engine failure. This is always done at V1 (the most critical moment for this to occur).

What is not trained is an engine failure in a climb above the acceleration altitude or an engine failure in cruise. These both require aircraft handling that is significantly different than what is required in the engine failure at V1 scenario.

It will be interesting to see how the training is done at TransAsia.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Canoehead »

Unbelievable...
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by ehbuddy »

that was my thought earlier in the string that the operating engine was shut down or feathered.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Meatservo »

I find it quite believable. More people have done this in the simulator than, I would hazard a guess, are willing to admit it. There but for the grace of god go I.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Cat Driver »

Engine failure actions for me is..

Do nothing for the first few seconds except fly the airplane......and absorb WTF happened.

That way I will be less apt to do something wrong fast.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by JigglyBus »

Cat Driver wrote:Engine failure actions for me is..

Do nothing for the first few seconds except fly the airplane......and absorb WTF happened.

That way I will be less apt to do something wrong fast.
It doesn't appear that this crew did anything significant for about 20 seconds after the failure.

Does anyone have any explanation for the multiple step down of PLA 1?
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by oldtimer »

One of my favorite expressions, given to me by a very experienced pilot. Never Do Anything Stupid -- Quickly.
I also read where a USAF C141 training captain said the first thing you do when an engine fails is to wind the clock.
Slow down and think.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by xsbank »

Part of the problem with training is that the authority must approve your syllabus and having been in Standards I know how long and complicated the process is. All of the exercises are mandated and must be accomplished in the time allotted for the simulator as nobody, client or in-house, will spend more money on the sim than necessary. Add to that the school needs to push so many through to make a profit of if an airline, so many crews have to be pushed through without taking too much time off line. V1 cuts are actually quite a good crew exercise and it's ( like Cat says) fuk'n amazing how many people don't know how to use the rudder.

What does work well is to do the check ride first. Then do the training. That seperates the serious from the drones.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Roar »

An old wise pilot once told me something that has stuck in my head for the past eighteen years of my career. That is when dealing with and engine failure in a multi engine aircraft never let yourself be worse off than you would be with an engine failure in a single.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by praveen4143 »

http://m.atwonline.com/manufacturers/tr ... eft-engine

Looks like they did indeed shut down the wrong engine! :shock:
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Bede »

I like the ITT @ 2154. Looks like they just finished the restart and ITT about to stabilize. Just ran out of time... Perhaps should have chosen the river a bit earlier...
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Meddler »

How long should a restart take in this aircraft? Too long in his case it seems. Does anyone teach, or at least try to learn for their own benifit, how to light the engines that they fly in a big hurry? Its probably not good for various systems, but with most smaller turbines, not in feather, it shouldn't take very long to go air-fuel-spark...whoosh
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Old fella »

Meddler wrote:How long should a restart take in this aircraft? Too long in his case it seems. Does anyone teach, or at least try to learn for their own benifit, how to light the engines that they fly in a big hurry? Its probably not good for various systems, but with most smaller turbines, not in feather, it shouldn't take very long to go air-fuel-spark...whoosh

Auto-ignition!!!!!
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by plhought »

Meddler wrote:How long should a restart take in this aircraft? Too long in his case it seems. Does anyone teach, or at least try to learn for their own benifit, how to light the engines that they fly in a big hurry? Its probably not good for various systems, but with most smaller turbines, not in feather, it shouldn't take very long to go air-fuel-spark...whoosh
It's pretty tough to start a triple-shaft free turbine engine any quicker in the air than on the ground.

The propeller has nothing to do with it unfortunately. Heck you can start these engines with the prop not moving (prop brake anyone?). Doesn't matter if it's in feather or fine. It unfortunately doesn't work like a jet regarding air-starts

In this case they likely still had DC Gen power from the #2 engine even though it was feathered. So at least they had a good power source for a start.

Having said that the human-process is pretty quick for the start on this. Turn knob couple clicks, press start, add gas. You are kind of at the mercy of the engine after that.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by golden hawk »

More on this...

http://www.flightglobal.com/news/articl ... ne-408790/
TransAsia GE235: Shutting down the wrong engine

By: David Learmount
London
Source: Flightglobal.com
14:51 6 Feb 2015


Taiwan's accident investigators have taken the unusual step of publishing part of the flight data recorder printout for the crashed ATR 72-600 almost as soon as it was available to them. There are no rules or protocols saying they must do so, and none saying they should not.

The printout they released concerns only the data for the engines. It is a series of graphical lines describing the state of 12 different engine parameters against a timeline, with barometric altitude also displayed. The graphs provide numerical values for some of those parameters; others just show whether a switch is on or off – like the fuel shut-off valve for example.

This data tells the investigators, in great detail, what happened, but still not – at this stage – why it happened.

The graph shows that the crew certainly suffered the engine "flame-out" they reported in a Mayday call to ATC: the turbine temperature for No 2 engine (the right-hand one) dropped, power was lost and the propeller auto-feathered.

But then, in the stressful situation prevailing from that point, the crew carried out the shutdown drill for the working engine, so it stopped too.

Why would the investigator release this information so soon without knowing the cause?

The investigators knew the information about this critical mistake would soon have to be released, and it looks as if they believed it would be better to publish the cold data that shows what occurred, rather than to make a statement – without releasing the data – that could be interpreted as a premature judgement about the human factors of this case.

Perhaps the most famous previous case in which a disaster occurred because an engine failed and then the crew mistakenly shut down the good engine (rather than the damaged one) was the British Midland Boeing 737-400 crash at Kegworth, UK, in 1989. In that case 47 of the 126 people on board died.

In the TransAsia case the total airborne time for flight GE235 was 2min 40s.

All was going well for 45s after take-off, but as the aircraft was climbing through about 1,200ft (pressure altitude) the turbine temperature for the No 2 engine dropped and the engine auto-feathered. It is not clear why. The aircraft continued to climb on the power from the remaining engine, reaching a maximum height of about 1,650ft.

But during that short period the crew allowed the power lever (throttle) of the failed No 2 engine to stay where it was, and started slowly pulling back the power lever of engine No 1 (the working left engine). When it had been reduced almost to idle setting, the fuel was shut off and the left engine also feathered. Just before they shut off fuel to No 1, they advanced the throttle of the failed No 2 engine as far as they could, as if it would provide them with additional power.

At that point there would have been a total absence of engine and propeller noise, but lots of alarms going off as systems lost their electrical power. From that time onward the crew had, as it turns out, 1min 15s of gliding time before hitting the surface. That is not really long enough to go through a successful engine re-start drill, but they did begin an attempt to re-light No 1 about 15s before impact.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Mig29 »

Can someone with some experience in Flight Safety/Investigation explain why has ATR released some data/details from the FDR/CVR tapes only few days after the crash? I know they said this is only "preliminary" and subject to change, but is it not a bit too soon? Even in the article above, the author said it was "unusual" that investigators would release the information so soon...

I only ask because when you look at to other accidents (MH17 and QZ8501), the FDR/CVR tapes have been recovered months ago, and nothing was yet released, even "preliminary", from respective manufacturers?
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by av8ts »

I don't think it's the manufacturer who releases the info. I believe it's up to the investigating body to make that decision.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Mig29 »

This was released by ATR...sorry I don't know how to attach the PDF files here :| ...


ALL OPERATORS MESSAGE

Date: 07 February 2015 Ref AOM: 72/2015/02 issue 2

This AOM is for information only and does not give instructions to Operators. It advises Operators of matters,
which are currently, either under investigation or dealt with by ATR. However, Operators may consider initiating
their own action. This AOM may be reissued to inform Operators of the closing action (Service Bulletin, No action
required, etc…).

Aircraft model : ATR72
SUBJECT: ATR 72-212A MSN 1141 Accident

REASON: The ATR72-212A manufacturing serial number 1141, registered B-22816 operated
by Transasia Airways had an accident on the 4th of February near Taipei Songshan
Airport at about 10:54 local time.
The aircraft was operating the flight GE-235 between Taipei and Kinmen with 58
persons on board.
Further to the initial flight data recorder (“FDR”) and cockpit voice recorder (“CVR”)
reading, the Taiwanese Aviation Safety Council published on the 6th of February a
bulletin disclosing preliminary factual information. An extract is provided here below:
“On February 4, 2015, TransAsia Airways passenger flight GE 235, an ATR 72-600 aircraft,
B-22816, took off from Songshan Airport at 1051 Taipei time for Kinmen Airport carrying two
pilots and one observer with 2 cabin crews and 53 passengers. Total 58 persons onboard.
Three minutes after takeoff, the aircraft lost contact and crashed into Keelung River.
According to emergency response unit, 35 death and 8 persons unaccounted until now.

Information collected by investigation team has been compiled and released on 6 Feb during
the press conference. …
GE235 flight received take off clearance from SongShan tower at 1051:13, after took off, at
1052:33.8 ATC controller requested the crew to contact Taipei approach. After 5 seconds,
(1052:38.3), master warning sounded in the cockpit associated with right engine(2) flame out
procedure message on display unit. The crew called it out. At 1053:04.0 the recorded
parameters indicated that the left engine power lever(1) was progressively retarded to flight
idle. At 1053:24, the left engine condition lever (1) was set to fuel shutoff position resulting in
left engine(1) shutdown. Between 1053:12.6 to 1053:18.8, several stall warnings sounded.
Flight crew declared an emergency at 1053:34.9 and reported an engine flame out. At
1054:09.2, flight crew called several time for engine restart. At 1054:20 the recorded
parameters indicates a restart of the left engine (1). At 1054:34.4, master warning sounded,
0.4 seconds later, CVR recorded unidentified sound. Both recorders stopped recording at
1054:36.
The above information are preliminary and subject to change. “

ALL OPERATORS MESSAGE

Date: 07 February 2015 Ref AOM: 72/2015/02 issue 2
For the time being, ATR has no specific recommendation towards ATR operating
fleet.
According to ICAO (International Civil Aviation Organization) regulations, ATR
will continue to advise the French Bureau d’Enquêtes et Analyses (BEA), safety
investigation authority representing the State of the aircraft manufacturer.
The Taiwanese Aviation Safety Council leading the investigations will be the official
source of information.

Didier CAILHOL
ATR Continued Airworthiness
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by cgzro »

It seems obvious to me why ATR would release the information, they want to emphasize the fact this appears to be pilot error and not a problem with their aircraft. Likely after a crash sales are impacted until a cause is released exonerating the aircraft. Also perhaps stops law suits early.. So basically its about money.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Mig29 »

I get the fact that ATR is "washing their hands" of this accident, but doesn't it seem a bit too soon by Indonesian investigators (and ATR) to release details about this crash?
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by MIQ »

I have to agree with what has been said above. Traditionally especially fatal air accidents always have two sorts of big impacts. The first one obviously being the impact on friends and families affected by the accident on a very personal and emotional level. The other one is on the pure business side of things where blame is being laid either on the aircraft manufacturer or the airline / pilots. Even though the main objective for air accident investigations is meant to be a non-punitive system which is implemented in order to make air travel a safer place and learn from mistakes in the past, in reality there's usually a lot of money at stake for both the manufacturer and the airline. I think one prime example for this in recent history would be the Air France Airbus that crashed en route from Brasil to France in the Atlantic Ocean. Air France was blaming Airbus for the crash and Airbus was blaming the Air France crew.
Because of the huge amount of money that is involved with the outcome of these investigations, I can imagine that official reports are often not released until either Airline and/or manufacturer found a why to defend themselves in public. That is purely my theory and could be total BS but I wouldn't be surprised if that's how these things are handled.
In the case of the TransAsia crash, like previously mentioned, ATR probably wanted to get the data out there quickly to prove that it wasn't a pure mechanical issue. In the public's eye, as portrayed by the media, it looks like a pure pilot's mistake. However, the preliminary release doesn't answer the question, why Engine #2 failed in the first place. At least TransAsia reacted accordingly by grounding their entire ATR flight for flight crew retraining purposes. As always it will be interesting to see when the full report is released.

Also, unrelated to that I have a question since so far I've never flown turbine twins. What are the steps in terms of 'Identify' and 'Verify' during an engine failure in turbine aircraft?
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by TG »

MIQ wrote: Also, unrelated to that I have a question since so far I've never flown turbine twins. What are the steps in terms of 'Identify' and 'Verify' during an engine failure in turbine aircraft?
Normally, the failed engine power level goes to flight idle, set by the PF but confirmed before by the PNF (identifying with gauges) Then the shutdown is accomplished by the PNF with each vital action confirmed before by the PF.
(1052:38.3), master warning sounded in the cockpit associated with right engine(2) flame out procedure message on display unit. The crew called it out.
At 1053:04.0 the recorded parameters indicated that the left engine power lever(1) was progressively retarded to flight idle.
At 1053:24, the left engine condition lever (1) was set to fuel shutoff position resulting in left engine(1) shutdown.
Between 1053:12.6 to 1053:18.8, several stall warnings sounded.
This has me baffle!
Not only the wrong power level was retarded but....20 second after starting this process, its corresponding condition lever was set to fuel shutoff! With stall warning in between!
Completely ignoring the steps of "identify, verify"



Whatever was going on, nobody was flying this aircraft.
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by Liquid Charlie »

It just looks like nobody was flying this aircraft.
Exactly -- as I said before if they had done nothing at all except fly the aircraft all would have been good -- I'm almost sure the aircraft had already looked after everything -- at least to the point of to have the ability to stay in the air ----
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Re: TransAsia Airways plane carrying more than 50 people cra

Post by co-joe »

I can't find the clip now but on tv I saw a map showing their heading excursions leading up to the crash. It looked like they never had a constant heading until probably both engines went quiet. Or was that just part of the departure procedure?

How are you supposed to identify, verify when you are in a right then left turn? Was the right turn after departure from the right engine failure then the left turn from shutting down the left engine? It is as if nobody had their feet on the rudder pedals at all.

Canoe can you decipher that graph a little? I'm confused with some of the numbers.
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