Loss of Airplane State Awareness (by Boeing)

26 Pages·2015·2.23 MB·English

by  James Wilborn

Loss of Control Due to Flight Crew Loss
of Airplane State Awareness:
Analysis and Safety Enhancements

Presented at RASG-AFI LOC-I symposium, Nairobi 22 June 2015
by
Chamsou Andjorin – The Boeing Company
Accident Categories
Change over time
Comparison of Fatalities 1993-2002, 1998-2007 and 2003-2012
Fatal Accidents – Worldwide Commercial Jet Fleet
3
| 3
Worldwide Fatal Jet Accidents 2003-2012
Airplane State Awareness Contribution
1648
(50)
External Fatalities [139]
Onboard Onboard Fatalities [4269]
External
971
(1)
765
(28)
202
154 153 154
(0)
(38) (12) (2) 121
96
(1) 1 4
(1)
(6) (0)
Fatal
18 17 16 3 5 2 2 2 1 7 2 4
Events
Worldwide Fatal Jet Accidents 2003-2012
Airplane State Awareness Contribution
1648
(50)
External Fatalities [139]
Onboard Onboard Fatalities [4269]
Attitude awareness [674]
External
971 Energy state awareness [596]*
(1)
765
(28) * does not include
Colgan 3407 or other
turboprop accidents
7
202
Events 154 153 154
(0)
(38) (12) (2) 121
6 96
(1) 1 4
Events (1)
(6) (0)
Fatal
18 17 16 3 5 2 2 2 1 7 2 5
Events
ASA Events 1998-2010
Colorado Springs, CO
CL-600
St. Louis, MO
Santa Maria, CA
EMB 145
Saab 340
Baltimore, MD
757-200 Philadelphia, PA Lubbock, TX
ATR 42
CL-600
Union Star, MO Buffalo, NY
717 DHC-8
Jefferson City, MO;
ASA JSAT
CL-600
Launched
98 99 00 01 02 03 04 05 06 07 08 09 10 11
Hsin-Chu Sharm Sochi
Saab 340 London el-Sheikh A320 Perm,
747-200F 737-300 Russia
Taipei 737-500
Oslo, Sulawesi Tripoli
A300
Bahrain Norway Newfoundland 737-400 France A330
Zurich
A320 757-200 DHC-8 A320
Saab 340 Beirut
Douala,
Amsterdam
737-800
Cameroon
India 737-800
Venezuela
737-800
737-200
MD-82
Mid-Atlantic
KEY Bournemouth, UK A330
ASA JSAT Attitude Events Incident 737-300 Yemen
A310
ASA JSAT Energy State Events Accident 6
ASA Analysis Set
Baltimore, MD
757-200 Lubbock, TX
ATR 42
Union Star, MO Buffalo, NY
717 DHC-8
ASA JSAT
Launched
98 99 00 01 02 03 04 05 06 07 08 09 10 11
Hsin-Chu Sharm Sochi
Saab 340 London el-Sheikh A320 Perm,
747-200F 737-300 Russia
737-500
Oslo, Sulawesi
Bahrain Norway Newfoundland 737-400 France
A320 757-200 DHC-8 A320
Douala,
Amsterdam
Cameroon
737-800
Venezuela
737-800
MD-82
KEY Bournemouth, UK
737-300
ASA JSAT Attitude Events Incident
ASA JSAT Energy State Events Accident 7
Example of Overbank from ASA Event Set
Kenya Airways 507 - Douala, Cameroon
Boeing 737-800 - May 5, 2007 - 114 fatalities
8
Example of Overbank from ASA Event Set
Kenya Airways 507 - Douala, Cameroon
Boeing 737-800 - May 5, 2007 - 114 fatalities
 During initial climb at 1000
ft AGL with autopilot
disconnected

 Bank angle increases from
20˚ to 35˚ over roughly
thirty seconds at normal g

 No initial input from the PF
(from CVR, crew likely
believes autopilot engaged):
loss of attitude awareness

 At 35˚ bank, PF control
wheel: right, left, right
(mostly right) over 20 sec

 Bank angle increases past
90˚ and vertical speed goes
9
from positive to negative
Accident: Kenya Airways 737-800 near Douala, Cameroon on 4 May 2007
UnRec SSppaattiiaall 4
Rec DDiissoorriieennttaattiioonn 5
Event Type: Loss of Attitude Awareness
Injuries/Fatalities: 114 fatalities: 108 passengers / 6 crew; no survivors; airplane destroyed LLaacckk ooff
Flight: Kenya Airways 507 Registration: 5Y-KYA EExxtteerrnnaall VViissuuaall 2
Local Time: 12:07 am Phase of Flight: Climb to Cruise RReeffeerreenncceess

Narrative Flight Crew
- Capt is PF; 8682 ttl hrs; type: 824 (Capt on 737-700/800); Impairment
1 - FO has 831 ttl hrs; type: 170; FO hadn’t had CRM training yet
- Flight crew training did not provide: UAR, SD Training 1
2 - Local weather: thunderstorms and moderate rain; 800 m visibility, scattered 300 ft,
Airplane
broken 1000 ft
Maintenance
- Initially canceled start-up due to heavy rain; prior to take-off they are focused on identifying
a departure corridor away from weather
Safety Culture
- On take-off the airplane has a tendency to bank right (not trimmed) and the Capt uses
small left wheel inputs to maintain wings level
Invalid Source Data
- At about 1000 ft, a period of 55 seconds commences where there are no control inputs;
airplane begins slowly rolling right DDiissttrraaccttiioonn
Dec Mak 3
3 - Attention at this time is on navigating through the weather
4 - 13 seconds after the last control input, Capt: “OK, command”; but the autopilot is not Systems
engaged (and there is no response from the FO); they are at 1600 ft and bank right of 11º Knowledge
- They are attempting to use the heading bug to maneuver around the weather for 40 more
seconds, but the heading bug has no effect since autopilot is not engaged. CCRRMM 4 8
5 - As bank angle nears 35º, the Capt exclaims and then EGPWS: “bank angle, bank angle”
AAuuttoommaattiioonn
6 - Capt makes wheel inputs to right, then left, then right with inputs to right dominating;
CCoonnffuussiioonn // 4 7
airplane rolls to 45º right
AAwwaarreenneessss
7 - They engage the autopilot but due to force on wheel, transitions into CWS-R
- Capt makes inputs to right and left, and pulls back on wheel; bank angle eventually reaches
IInneeffffeeccttiivvee
115° to the right, but is recovered to 70° right
5
AAlleerrttiinngg
- The FO states, “right captain, left, left, left, correction left.”
8 - Capt and FO are both on controls; Capt rolling right; FO rolling left
IInnaapppprroopprriiaattee
6
CCoonnttrrooll AAccttiioonnss
Example of Speed Decay/Stall from ASA Event Set
West Caribbean Airways 701 – Venezuela
Boeing MD-82 - August 15, 2005 - 160 fatalities
 Engine anti-ice turned
off to climb to FL330

 Engine anti-ice re-
engaged; EPR
reduced

 A/P in altitude hold

 Airspeed and Mach
decay over next 10
minutes

 Autopilot
disconnected

 Stall warning – pilot
responds with full aft
column and NU trim