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We make a special effort here to record the facts as we receive them. At times, there may be error but we do try to use our best judgement at the time of posting, and will be glad to amend any details which are proved incorrect. Furthermore, even though we do not here discuss the human cost, we realize that losing anyone in an air accident is insurmountable tragedy to individuals, families and communities. We do extend our heartfelt sympathy to those whose loss we record here. "...any man's death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls, it tolls for..." us all.
Meditation XVII - (with apologies to) John Donne


2009/03/07

Thoughts on the Turkish Airlines Boeing 737-800

According to the Preliminary Dutch Safety Board Report, "The Board is of the opinion that extra attention is needed for the role of the radio altimeter when using the automatic pilot and the automatic throttle system. The Board has issued a warning for Boeing today requesting extra attention to a part of a manual for the Boeing 737, in which is stated that in case of malfunction of the radio altimeter(s), the automatic pilot and throttle system that are connected to this may not be used for approach and landing. The Board would like Boeing to consider an investigation into whether this procedure is also applicable during flight. With the exception of the malfunction of the left radio altimeter the investigators of the Dutch Safety Board have not yet found any irregularities.

One question that remains now is how Boeing is going to follow up with the reminder for pilots to pay attention. Is this going to be handled with additional training or aircraft or procedure modifications? However--Boeing has said that the autopilot system is designed so that if it senses faulty data from the captain's altimeter on the left side, the auto-throttle is supposed to switch to the altimeter on the right. In fact, AVweb summarizes it this way: " The autopilot initiated a power-down of the engines in preparation for landing and the airplane slowed to near stall speed. The pilots responded to the situation too late."

It seems to us like this is more of a problem of maintenance and pilot training at Turkish Airlines. How could the pilots not have noticed flying for more than a minute with no thrust?

We are eager to see what is going to be done to prevent a repetition of catastrophe. On Wednesday Boeing listed six warning signs that can alert a pilot that something is wrong with the altimeter. Maybe they should have included a Starbucks gift certificate for that extra jolt of caffeine-fueled pilot attentiveness.

The Dutch report indicates that the faulty radio altimeter initiated a sequence of events to which the pilots responded too slowly. The thing is that being a pilot means being aware. There is no margin for error.

Plus, any time I see that an automatic system did the thinking, it makes me pause: "the automatic system – with its engines at reduced power – assumed it was in the final stages of the flight." If the autothrust/pilot starts to do something unusual, it is the pilot's responsibility to disconnect it and fly the aircraft manually.

Another thing that seems crucial is the black box data:
"The black box – which can register 25 hours of flying time and which, in this case, covered 8 flights- showed that this problem had occurred twice previously in a similar situation, before landing." It is crucial in conflicting ways. When it happened before, why was there no "crash" situation? How was it averted? (Probably the pilots flew in manually.)

And...if it happened before, doesn't it make the faulty radio altimeter a "known problem" and therefore one which the carrier should have corrected before this plane ever went out again?

For those who survived, it really doesn't matter why it happened.

The passengers--those who perished and those who were injured and those who lucked out and got away without a scrape (if there are any)--are innocents who purchased a ticket.

There's no one on that plane who will ever board a plane again without thinking twice; some will suffer sleepless nights and develop phobias; and some have paid the ultimate price, losing their health, or their life.

Now they are owed a lot more than a refund.

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