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Pilot Heroically Breaks Rules to Save Boeing 747 & Athens from Disaster!
The incident took place the 9th of August, 1978. Olympic Airways is the airline involved. It was owned by the Greek state after the previous owner Aristole Socrates Onassis. sold his stake in his company after his son Alexander Onassis died in an aviation accident back in 1973. The flagship of the company was its Boeing 747 - 200. It was used for their most prestigious routes, one of them relying Athens to New York. Ellinikon international airport was the main airport in Athens back then, with 2 parallels runways : Runway 33 right and Runway right 15 left. The other parallel runway was mainly used as a taxiway. This day was 43 degrees Celcius warm and when it's warm in Athens, it's normally coming with a northwesterly westerly breeze which was the case on this day as well. Rnuway 33, used most of the time, was facing the city straight in the center downtown. Becauafter departure was an immediate left hand turn out of the sea. Athens is surrounded on 3 side sby high terrain so the only way to avoid that is out over the sea on the southwest to west side. Sifis Migadis was an experienced pilot. Here he wsa flying with a close friend, the first officer Kostas Fikardos and a flight engineer named Tribos. Thie Boeing was equipped with 4 Pratt and Whitney JT9D/7A engines. Under normal circumstances those engines could produce over 46 000 pounds of thrust which is a lot. But on August 9th there have been some maintenance on number 2 engine. Because of that it had 96% of the available thrust. It was supposed to be an over 11 hours of flight with 140 tons of fuel on board and 398 passengers + 20 crew. Core temperature limits the thrust of the engine. If you put too much fuel into the combustion chamber, the core temperature will rise so high it will damage the components following the combustion chamber which are the turbine stages. Now there are ways to mitigate that, to get the temperature down and thus to be able to put more fuel in and create more thrust.
These engines had a system, water glycol mixture into the diffuser just prior to the combustion chamber By doing so it cools down the flame which would enable the engine to pur more fuel in to start burning. Together with the cooling effect, that actually saved the components behind the combustion and the increase of mass that was flowing through the engine, the engine thrust could be increased to 110% of its normal thrust. In this case this meant going from a thrust of 46 150 pounds to a thrust of 47 670 pounds. Drawback was that when you introduce water glycol mixture into the combustion chamber like this, that will cause a lot of unburned fuel to be pushed out through the engine. The 747 200 was not the only aircraft doing this. B 52 bombers used the same system taking off with these huge black plumes coming out behind them. Obviosuly it's not very environmentally friendly. You also had to carry the extra weight on the water glycol during the takeoff. Pilots had to calculate whether or not it was worth it to get that extra thrust. The water glycol was stored in 2 huge tanks just behind the landing lights in the wing root of the Boeing. Each tank held about 2 300 kg of water and once it was started that would last about 2 and a half minutes. During this time you get the extra thrust. After that you had to be very quick to reduce the thrust back again so that you woudln't damage the engines. The flight engineer was the one who activated it during the taxi before entering on the runway. He switched on the pumps, giving him a couple of low pressure lights that would extinguish when the water pressure was right. That would also give him 4 green lights telling him that the system was ready. A common problem with that was that during the shutdown phases, the shutof valves inside of the engines wouldn't shut completly.
So that when the flight engineer activated the system, the pump would start producing pressure and since the valve was still a bit open, the full water pressure would just go straight into the engine and this would cause something called a steam out or a piss out where the engine would just shut down, the system would have to be turned off and then that engine had to be restarted again. If the system worked properly then the system would be armed as the pilot would set take off thrust. When the thrust reached about 1.25 point EPR, the valves would open, water glycol would be introduced and the extra thrust will be available. Pilots would set a higher than normal thrust setting higher than normal EPR. Then they will have to carefully monitor the EGT, the exhaust gas temperature because if they were during the takeoff roll and for example one of the water pumps would fail, the engine will still be set a higher EPR, the water or the wet takeoff thrust and there wouldn't be any cooling from the water and the engine could quickly fail then. On this flight some reports say that the flight engineer accidentally switched the system off instead of on during the takeoff roll. But pilots would have a green indicator light in front of them showing that the system was operating. Something more likely is that one of the pumps failed during the takeoff roll, causing the subsequent failure.
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Pilot Heroically Breaks Rules to Save Boeing 747 & Athens from Disaster!
The incident took place the 9th of August, 1978. Olympic Airways is the airline involved. It was owned by the Greek state after the previous owner Aristole Socrates Onassis. sold his stake in his company after his son Alexander Onassis died in an aviation accident back in 1973. The flagship of the company was its Boeing 747 - 200. It was used for their most prestigious routes, one of them relying Athens to New York. Ellinikon international airport was the main airport in Athens back then, with 2 parallels runways : Runway 33 right and Runway right 15 left. The other parallel runway was mainly used as a taxiway. This day was 43 degrees Celcius warm and when it's warm in Athens, it's normally coming with a northwesterly westerly breeze which was the case on this day as well. Rnuway 33, used most of the time, was facing the city straight in the center downtown. Becauafter departure was an immediate left hand turn out of the sea. Athens is surrounded on 3 side sby high terrain so the only way to avoid that is out over the sea on the southwest to west side. Sifis Migadis was an experienced pilot. Here he wsa flying with a close friend, the first officer Kostas Fikardos and a flight engineer named Tribos. Thie Boeing was equipped with 4 Pratt and Whitney JT9D/7A engines. Under normal circumstances those engines could produce over 46 000 pounds of thrust which is a lot. But on August 9th there have been some maintenance on number 2 engine. Because of that it had 96% of the available thrust. It was supposed to be an over 11 hours of flight with 140 tons of fuel on board and 398 passengers + 20 crew. Core temperature limits the thrust of the engine. If you put too much fuel into the combustion chamber, the core temperature will rise so high it will damage the components following the combustion chamber which are the turbine stages. Now there are ways to mitigate that, to get the temperature down and thus to be able to put more fuel in and create more thrust.
These engines had a system, water glycol mixture into the diffuser just prior to the combustion chamber By doing so it cools down the flame which would enable the engine to pur more fuel in to start burning. Together with the cooling effect, that actually saved the components behind the combustion and the increase of mass that was flowing through the engine, the engine thrust could be increased to 110% of its normal thrust. In this case this meant going from a thrust of 46 150 pounds to a thrust of 47 670 pounds. Drawback was that when you introduce water glycol mixture into the combustion chamber like this, that will cause a lot of unburned fuel to be pushed out through the engine. The 747 200 was not the only aircraft doing this. B 52 bombers used the same system taking off with these huge black plumes coming out behind them. Obviosuly it's not very environmentally friendly. You also had to carry the extra weight on the water glycol during the takeoff. Pilots had to calculate whether or not it was worth it to get that extra thrust. The water glycol was stored in 2 huge tanks just behind the landing lights in the wing root of the Boeing. Each tank held about 2 300 kg of water and once it was started that would last about 2 and a half minutes. During this time you get the extra thrust. After that you had to be very quick to reduce the thrust back again so that you woudln't damage the engines. The flight engineer was the one who activated it during the taxi before entering on the runway. He switched on the pumps, giving him a couple of low pressure lights that would extinguish when the water pressure was right. That would also give him 4 green lights telling him that the system was ready. A common problem with that was that during the shutdown phases, the shutof valves inside of the engines wouldn't shut completly.
So that when the flight engineer activated the system, the pump would start producing pressure and since the valve was still a bit open, the full water pressure would just go straight into the engine and this would cause something called a steam out or a piss out where the engine would just shut down, the system would have to be turned off and then that engine had to be restarted again. If the system worked properly then the system would be armed as the pilot would set take off thrust. When the thrust reached about 1.25 point EPR, the valves would open, water glycol would be introduced and the extra thrust will be available. Pilots would set a higher than normal thrust setting higher than normal EPR. Then they will have to carefully monitor the EGT, the exhaust gas temperature because if they were during the takeoff roll and for example one of the water pumps would fail, the engine will still be set a higher EPR, the water or the wet takeoff thrust and there wouldn't be any cooling from the water and the engine could quickly fail then. On this flight some reports say that the flight engineer accidentally switched the system off instead of on during the takeoff roll. But pilots would have a green indicator light in front of them showing that the system was operating. Something more likely is that one of the pumps failed during the takeoff roll, causing the subsequent failure.
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How Did EVERYONE Miss THIS!? | Malaysian Airlines Flight 134
On this Airbus A330, none of the speed indicators were working properly. From ramp handlers to gate agents, pilots, cabin crew, engineers, almost everyone in the airport has a safety mission.Mud wasps are insects who like to build their cavities in man made cavities. They can be found pretty much all over Australia but they are most prevalent in tropical areas, so along of the east seaboard close to Brisbane. Turns out aircrafts have a lot of little holes in them especially the pilot tubes on the aircraft who seem to have a perfect diameter of a hole for a mud wasp to call it home. These pilot probes have a little hole in front of them for a specific reason. The probes measure dynamic pressure as in the wind and then they subtract the static pressure. The difference between the static pressure and dynamic pressure is the aircraft airspeed which is something that pilots need to fly safely. That's why there are generally at least 3 different pilot probes on every commercial aircraft so pilots have 3 independent sources of airspeed. There were studies about how fast mud wapss could infest a pilot probe if they were around It was found that 20 minutes from when the aircraft stopped at the gate before one of these mud wasp would be here. Between 201 and 2018, the authorities in the airport realized they couldn't get rid of mud wasps, the infestation was too far along. Instead they sent warning letters to operators that was operating into the airport telling them that if they planned to have a long turnaround on the ground or an overnight stay that they needed they needed to start putting thse pilot probes covers on top of their pilot probes. Pilot probe cover is like a little mitten that you put over it and fasten it to the back. It tends to have a long streamer hanging below it so that is conspicuous, it's easy to see. Malaysia Airlines flied on Brisbane airport before but during the years where infestations started, they were on a commercial break from flying there.
But just before the incident they decided to start flying here again with A330. Prior to the operation they have been notified about the infestation however for a different reason they had not been communicated to the pilot and to the line maintenance engineers. This brings us to June 18th, 2018. Plane stayed at the ground for 3 hours upon arrival until the next pilots and cabin crew would fly the aircraft back to Kuala Lumpur. A flight engineer had been dispatched from Kuala Lumper to Brisbane to do 2 turnaround checks. He was going to travel back on that plane this evening. Since he wasn't based in Brisbane he didn't have access to any tooling or oil or anything he really needed so he needed the help of an assistant engineer that was locally based. Assistant engineer arrived with 3 pilot probe covers. After that he came into the cockpit, introducing himself to the line assist engineer Line assistant engineer didn't understand what the assistant engineer told about the pilot probe covers because he wasn't expecting to hear that. Line assist engineer noticed the probe pilot covers and was confused because he didn't ask for them and had no idea about the mud wasp problem so he made a mental note to himself to tell the assistant engineer to remove them. When the assistant engineer came back, they started to replenish the oils that they discussed before. and the line asssist engineer was in charge of fueling so he forgot about the pilot probe covers. The flight crew consisted of 2 inexperienced pilots. The captain had more than 14 400 hours of total time but he had most of that time on Boeing 737 and Boeing 747 than A330 and had only 555 hours on that aircraft. Captain's training records showed that he was of average to good abilities and there was only some small notes about his hand flying capabilities. Alongside him, the first officer had a total of 6 500 flight hours, the majority of them being spent on the Airbus A330.
So on the type he was more experienced than the captain. They decided that the first officer was going to be the pilot for the flight with the captain being pilot monitoring and he was the one that needed to do the pre flight walkaround. The fueling was completed and the line assist engineer took the fuel receipt and brought it up to the cockpit where he met with the flight crew and discussed what had been done to the aircraft. Assistant engineer asked the line assist engineer if he needed help with anything else. Line assistant engineer said that everything was good. Walkaround was short and the captain didn't see that the pilot probe covers were still installed even through the streamers were hanging on from them.It's probably inattention blindness. This means that you are watching something but actually not seeing it. It's common when faced with things that are out of sequences. Through pre start checklist, the checklist includes the item gear pins and covers. First officer responds " removed " to that item. In the cockpit of this plane, there are supposed to be both gear pins, those are the pins that are installed into the landing gears and the nose gear so that the aircraft can be towed safely. Probe covers are supposed to be in the cockpit so you can take them out and verify that if you have any of them, you know that no probe covers are fitted outside. But in Malaysian Airlines it became an habit to not have these probe covers installed in the cockpit because they have been so rarely used that they have been removed from them from most cockpits. So they started rhyming that part of the checklist. Don't do that because if something doesn't make sense or if it doesn't conform the checklist, it needs to be investigated. In this case these probe covers were installed by the airport so it's possible that the crew actually had them in the cockpit but that doesn't mean that they were actually removed from the outside.
Another last way to prevent this thing from happening. Tow bar was fitted so they were ready to start the pushback procedure. In Brisbande airport they have a person called the leading hand, basically the lead dispatcher of the aircraft. He will be responsible of any turnaround that is not maintenance related so for example loading passengers, loading of the aircraft and the very last walkaround before the pushback continues. In that acse the company recently changed handling provider and the leading hand supposed to do this pushback was not sure that he received the proper training to do this part of the pushback procedure so he contacted a leading hand who dealt with another aircraft and asked that person to help him. He assumed that the new person coming in was going to be the final walkaround of the aircraft where you check that all doors and hatches are closed and all probe covers are removed. The new person that came assumed that the previous person had done it so no one did the last walkaround of that aircraft. Once the pushback is completed the leading hand removes his headset and with the pushback truck, together start moving away from the aircraft. At this point, 4 people in different walkarounds missed the fact that the pilot probe covers are still installed on the aircraft. When the plane passes 30 knots on his takeoff phase in the runway, normally the airspeed indicator starts becoming alive. But here nothing happens. Then a red speed flag appears on both primary flight displays because the aircraft has done an internal comparision between the ground speed and the indicated airspeed. When it shows these flags it's clear that something is wrong here. 100 knots indicate the difference between the low speed regime and the high speed regime in Airbus aircraft. In the low speed regime, the pilots are taught to reject the takeoff for any type of warning.
If you are into the high speed regime, pilots are trained to keep going, to be go minded and only stop for things like engine failures, engine fire, predictive windshear warning or if the aircraft is deemed unsafe to fly. As it continues to accelerate, the forst officer asks " Go to ADR 3 " which means he wants the captain to switch to the Air Data Reference unit number 3 which provides a secondary source for the airspeed indication. But it's not time to do this. This forms part of a non normal checklist that you do when you have time to do so but not during takeof when you still have possibility to reject the takeoff. As the first officer initiates the rotation of the aircraft after passing V1, the captain calls out : " You rotated on ground speed? " And the rotation continues. Airspeed are rarely the reason pilots reject takeoff. The reason for that is because of airspeed indications and the problem with those are insidious and they are very different. Almost everytime there is a problem with airspeed, it manifests itself in different ways. So either you might have airspeed indications on one side and not the other, sometimes both doesn't work or all 3 doesn't work and it's not associated with any aural warning. If you try to figure out what's going on rather than realizing that something is going on and rejecting the takeoff, your mental processes are going to be severly limited by the now increasing time pressure as the speed is increasing and the stress that comes with that. As soon as the aircraft is airborne, a master caution warning can be heard and an ECAM message saying autoflight, autothrust off is seen . The first officer calls it out and the captain responds with " Positive rate. " First officer responds " Gear up ". Captain retracts the landing gear. The aircraft climbs without any airspeed indication. Flags are momentarily changed into indicated airspeed but the airspeed never goes higher than about 50 knots.
How Did EVERYONE Miss THIS!? | Malaysian Airlines Flight 134
On this Airbus A330, none of the speed indicators were working properly. From ramp handlers to gate agents, pilots, cabin crew, engineers, almost everyone in the airport has a safety mission.Mud wasps are insects who like to build their cavities in man made cavities. They can be found pretty much all over Australia but they are most prevalent in tropical areas, so along of the east seaboard close to Brisbane. Turns out aircrafts have a lot of little holes in them especially the pilot tubes on the aircraft who seem to have a perfect diameter of a hole for a mud wasp to call it home. These pilot probes have a little hole in front of them for a specific reason. The probes measure dynamic pressure as in the wind and then they subtract the static pressure. The difference between the static pressure and dynamic pressure is the aircraft airspeed which is something that pilots need to fly safely. That's why there are generally at least 3 different pilot probes on every commercial aircraft so pilots have 3 independent sources of airspeed. There were studies about how fast mud wapss could infest a pilot probe if they were around It was found that 20 minutes from when the aircraft stopped at the gate before one of these mud wasp would be here. Between 201 and 2018, the authorities in the airport realized they couldn't get rid of mud wasps, the infestation was too far along. Instead they sent warning letters to operators that was operating into the airport telling them that if they planned to have a long turnaround on the ground or an overnight stay that they needed they needed to start putting thse pilot probes covers on top of their pilot probes. Pilot probe cover is like a little mitten that you put over it and fasten it to the back. It tends to have a long streamer hanging below it so that is conspicuous, it's easy to see. Malaysia Airlines flied on Brisbane airport before but during the years where infestations started, they were on a commercial break from flying there.
But just before the incident they decided to start flying here again with A330. Prior to the operation they have been notified about the infestation however for a different reason they had not been communicated to the pilot and to the line maintenance engineers. This brings us to June 18th, 2018. Plane stayed at the ground for 3 hours upon arrival until the next pilots and cabin crew would fly the aircraft back to Kuala Lumpur. A flight engineer had been dispatched from Kuala Lumper to Brisbane to do 2 turnaround checks. He was going to travel back on that plane this evening. Since he wasn't based in Brisbane he didn't have access to any tooling or oil or anything he really needed so he needed the help of an assistant engineer that was locally based. Assistant engineer arrived with 3 pilot probe covers. After that he came into the cockpit, introducing himself to the line assist engineer Line assistant engineer didn't understand what the assistant engineer told about the pilot probe covers because he wasn't expecting to hear that. Line assist engineer noticed the probe pilot covers and was confused because he didn't ask for them and had no idea about the mud wasp problem so he made a mental note to himself to tell the assistant engineer to remove them. When the assistant engineer came back, they started to replenish the oils that they discussed before. and the line asssist engineer was in charge of fueling so he forgot about the pilot probe covers. The flight crew consisted of 2 inexperienced pilots. The captain had more than 14 400 hours of total time but he had most of that time on Boeing 737 and Boeing 747 than A330 and had only 555 hours on that aircraft. Captain's training records showed that he was of average to good abilities and there was only some small notes about his hand flying capabilities. Alongside him, the first officer had a total of 6 500 flight hours, the majority of them being spent on the Airbus A330.
So on the type he was more experienced than the captain. They decided that the first officer was going to be the pilot for the flight with the captain being pilot monitoring and he was the one that needed to do the pre flight walkaround. The fueling was completed and the line assist engineer took the fuel receipt and brought it up to the cockpit where he met with the flight crew and discussed what had been done to the aircraft. Assistant engineer asked the line assist engineer if he needed help with anything else. Line assistant engineer said that everything was good. Walkaround was short and the captain didn't see that the pilot probe covers were still installed even through the streamers were hanging on from them.It's probably inattention blindness. This means that you are watching something but actually not seeing it. It's common when faced with things that are out of sequences. Through pre start checklist, the checklist includes the item gear pins and covers. First officer responds " removed " to that item. In the cockpit of this plane, there are supposed to be both gear pins, those are the pins that are installed into the landing gears and the nose gear so that the aircraft can be towed safely. Probe covers are supposed to be in the cockpit so you can take them out and verify that if you have any of them, you know that no probe covers are fitted outside. But in Malaysian Airlines it became an habit to not have these probe covers installed in the cockpit because they have been so rarely used that they have been removed from them from most cockpits. So they started rhyming that part of the checklist. Don't do that because if something doesn't make sense or if it doesn't conform the checklist, it needs to be investigated. In this case these probe covers were installed by the airport so it's possible that the crew actually had them in the cockpit but that doesn't mean that they were actually removed from the outside.
Another last way to prevent this thing from happening. Tow bar was fitted so they were ready to start the pushback procedure. In Brisbande airport they have a person called the leading hand, basically the lead dispatcher of the aircraft. He will be responsible of any turnaround that is not maintenance related so for example loading passengers, loading of the aircraft and the very last walkaround before the pushback continues. In that acse the company recently changed handling provider and the leading hand supposed to do this pushback was not sure that he received the proper training to do this part of the pushback procedure so he contacted a leading hand who dealt with another aircraft and asked that person to help him. He assumed that the new person coming in was going to be the final walkaround of the aircraft where you check that all doors and hatches are closed and all probe covers are removed. The new person that came assumed that the previous person had done it so no one did the last walkaround of that aircraft. Once the pushback is completed the leading hand removes his headset and with the pushback truck, together start moving away from the aircraft. At this point, 4 people in different walkarounds missed the fact that the pilot probe covers are still installed on the aircraft. When the plane passes 30 knots on his takeoff phase in the runway, normally the airspeed indicator starts becoming alive. But here nothing happens. Then a red speed flag appears on both primary flight displays because the aircraft has done an internal comparision between the ground speed and the indicated airspeed. When it shows these flags it's clear that something is wrong here. 100 knots indicate the difference between the low speed regime and the high speed regime in Airbus aircraft. In the low speed regime, the pilots are taught to reject the takeoff for any type of warning.
If you are into the high speed regime, pilots are trained to keep going, to be go minded and only stop for things like engine failures, engine fire, predictive windshear warning or if the aircraft is deemed unsafe to fly. As it continues to accelerate, the forst officer asks " Go to ADR 3 " which means he wants the captain to switch to the Air Data Reference unit number 3 which provides a secondary source for the airspeed indication. But it's not time to do this. This forms part of a non normal checklist that you do when you have time to do so but not during takeof when you still have possibility to reject the takeoff. As the first officer initiates the rotation of the aircraft after passing V1, the captain calls out : " You rotated on ground speed? " And the rotation continues. Airspeed are rarely the reason pilots reject takeoff. The reason for that is because of airspeed indications and the problem with those are insidious and they are very different. Almost everytime there is a problem with airspeed, it manifests itself in different ways. So either you might have airspeed indications on one side and not the other, sometimes both doesn't work or all 3 doesn't work and it's not associated with any aural warning. If you try to figure out what's going on rather than realizing that something is going on and rejecting the takeoff, your mental processes are going to be severly limited by the now increasing time pressure as the speed is increasing and the stress that comes with that. As soon as the aircraft is airborne, a master caution warning can be heard and an ECAM message saying autoflight, autothrust off is seen . The first officer calls it out and the captain responds with " Positive rate. " First officer responds " Gear up ". Captain retracts the landing gear. The aircraft climbs without any airspeed indication. Flags are momentarily changed into indicated airspeed but the airspeed never goes higher than about 50 knots.
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The heating of probe are still burning through the covers so a bit of air is escaping into the pilot probes but it's never close to the kind of airspeed that is should be They have some speed information from the IRS calculated groud speed indicators but since the air data computers have been told to disregard the position of the alpha vane as in the Angle of Attack vanes when the airspeed is less than 60 knots, that's now what the air data computers are telling them. It means the aircraft goes on from normal law where there are plenty of protections for the flight envelope of the aircraft into alternate law which is a degraded mode that doesn't offer as much protections to the flight crew. Initially, the first officer is pitching for about 13 degrees nose up and he keeps the thrust in the flex detent. At this point he should be doing the airspeed unreliable memory items which includes pitching to 15 degrees and adding full thrust but this doesn't happen. Instead at 300 feet, the first officer asks the captain, " Did you put it to ADR? " The captain mutters something in response but it can be seen on flight data recorder that the air data source is being changed over to ADR 3 at this point. That doesn't solve anything because all 3 pilot probes are covered with pilot covers so the aircraft just continue to climb. At 700 feet the first officer reduces the thrust back to max contunuous thrust. He lowers the nose to 7 degrees pitch up and as they pass 1 000 feet, the first officer asks the captain to start actionning the ECAM actions for the auto flight, auto thrust off message that they got earlier. The captain does this and as they pass 1 500 feet they get the next master caution warning. The time they get an ECAM message saying that they are in alternate law. Control tower calls the aircraft to tell them to switch over to the departure frequency.
The captain asks them to repeat what the frequency is and as he is responding this, the first officer mentions to the captain that maybe they should get a pan pan call.
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The heating of probe are still burning through the covers so a bit of air is escaping into the pilot probes but it's never close to the kind of airspeed that is should be They have some speed information from the IRS calculated groud speed indicators but since the air data computers have been told to disregard the position of the alpha vane as in the Angle of Attack vanes when the airspeed is less than 60 knots, that's now what the air data computers are telling them. It means the aircraft goes on from normal law where there are plenty of protections for the flight envelope of the aircraft into alternate law which is a degraded mode that doesn't offer as much protections to the flight crew. Initially, the first officer is pitching for about 13 degrees nose up and he keeps the thrust in the flex detent. At this point he should be doing the airspeed unreliable memory items which includes pitching to 15 degrees and adding full thrust but this doesn't happen. Instead at 300 feet, the first officer asks the captain, " Did you put it to ADR? " The captain mutters something in response but it can be seen on flight data recorder that the air data source is being changed over to ADR 3 at this point. That doesn't solve anything because all 3 pilot probes are covered with pilot covers so the aircraft just continue to climb. At 700 feet the first officer reduces the thrust back to max contunuous thrust. He lowers the nose to 7 degrees pitch up and as they pass 1 000 feet, the first officer asks the captain to start actionning the ECAM actions for the auto flight, auto thrust off message that they got earlier. The captain does this and as they pass 1 500 feet they get the next master caution warning. The time they get an ECAM message saying that they are in alternate law. Control tower calls the aircraft to tell them to switch over to the departure frequency.
The captain asks them to repeat what the frequency is and as he is responding this, the first officer mentions to the captain that maybe they should get a pan pan call.
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DISAPPEARING Engine! The Incredible story of Nationwide 723
In the plane, there are 4 cabin crew and 2 pilots. Marilyn Rink was the cabin controller, one of the most experienced cabin crew member of the airline. The captain was the 50 years old Trevor Arnold, experienced pilot with 13 860 hours at the time of the flight including 3 277 hours on the Boeing 737 - 200. He started flying for Nationwide back in 1997 and had been been during a few years flying for other operators until 2006 when he came back again. By contrast, his first officer was Daniel Perry , 25 years old He was brand new on this job, starting flying for Nationwide only 1 month before this flight with a total flying hours of 1 000 hours only including 278 hours on the type which he had gotten his type rating on earlier that same year. Captain was skilled operator and a stickler for following rules and standard operating procedures. For the first officer it was probbaly a good new because the less experienced you are, the more important it's that everyone follows procedures. That's the only thing you have to hold on into until your experience builds up. Pre flight briefing was okay. Just light rain in Cape Town, northerly winds and a layer of clouds. The plane was part of the very first variance of the 737 family called " The Originals ". Most of us just refer to them as " The Jurassics ". Thie aircraft handled just like a sport car. This particular 737 - 200 advanced model first came out in 1971 and it was equipped with slightly more powerful Pratt and Whitney JT8D-15 engines, improved aerodynamics auto brakes and a higher fuel capacity compared to the original 200 giving it a better range and overall efficiency. The 2 engines were low bypass ratio turbofan engines, making them long and thin.
They were used because when Boeing were designing the original 737 they wanted an aircraft that would have a low ground clearance so they could be easy to work on for ground handlers since Boeing assumed that it would mainly operate into smaller airports where the facilities might not be that great. This meant that the engines were mounted directly onto the wings without without any pylons. The engines were attached with 2 main mounts, one forward and one aft and thena secondary support assembly forward of tha aft engine mount behind. The engine supports are bolted onto the wing using cone bolts which are constructed to hold up for any normal loads that the engine might experience But if a strong enough force is applied to them, for eample if a gear up landing would happen, the bolts were designed to shear off and release the engines and therefore protect the wing and overall airplane main structure. It was very important that these bolts were mounted correctly with the exact amout of torque applied to them to avoid over stressing the bolts which could lead to metal fatigue. to avoid over stressing the bolts, which could lead to metal fatigue. This was a known issue especially on the older type of engine mouts that were fitted to this particular aircraft. So the FAA issued an airworthiness directive several years earlier outlining strict inspection intervals to be done at least every 700 cycles of these mounts and bolts.
At the time of the accident, Nationwide were operating 11 Boeing 737 - 200s. They were doing all their maintenance in house in their own maintenance organization But prior to 2007 the organization faced some problems. Key management personnel most often the quality manager ended up quitting their jobs just prior to the renewal audits of the Air Maintenance Organization or AMO approval. Because the audits always highlightened several non compliances with existing rules and regulations Most of these findings were never properly addressed or closed which is why, like unbeknown to the pilots, the AMO was lacking a formal license to operate at the time of the accident. The maintenance work continued to be done based on an unofficial mail sent from the South African Civil Aviation authorities allowing them to continue for now. But there didn't exist any provisions for such an extension. One of the findings that were later revealed was that the accident aircraft didn't have any records of any inspections of the engine mounts for the previous 5 years prior to the accident. Pilots were unaware of this. Only thing pilots can do is to verify that all documentation is available and that all applicable certification dates are in date and obviously that the aircraft looks good during the walkaround. The plane was taking off, soon reaching the high speed regime of the takeoff from which is a rejected takeoff is only executed if an engine failure, fire, or a predictive windshear warning is heard, or if the runway is blocked or the aircraft is unsafe or unable to fly. Reason pilots only reject for those things above 80 knots is because it's normally safer from that position to take the aircraft into the air and deal with whatever problem you might have when you are already airborne. This will give more time to think and troubleshoot and pilots will then have the full use of the whole runway for landing if you then decide to come back.
Aircraft would have used a lot of runway accelerating up to this point. And the speed would be relatively high so even though it would be possible the stop the aircraft safely all the way up to the decision speed of V1. It would likely be safer and better to just bring any minor problem into the air. That's what pilots call being go minded. Most airlines adopted this philosophy today. Just before the plane took off, something went wrong on the right wing when the aft cone bolt which was holding the engine in place had developed a small fatigue crack and during the rotation, the crack suddently gave away and the bolt fractured. In normal conditions, the secondary engine support assembly is supposed to be able to hold the load if the aft mounts fails. But this secondary support also failed. Secondary support was never found after the accident so we don't know what happened. Either it also broke from the strain or as some newspapers reported after the accident, it might not have been fitted at all after the last engine overhaul. Anyway now nothing was holding the back part of the engine in place while it was still producing full takeoff thrust. This basically transformed the forward engine mount into a pivot point around which the engine could move. The consequence was that now the engine started to swing forward and upwards. Since the thrust levers were mechanically connected via a control wire to the engine, this wire was now pulled back with the full force of the departed engine which caused the right engine thrust lever in the cockpit to whisk backyard and slam into the pedestal so hard that it left a deep indentation to it. Other consequence was the right engine started producing an upward thrust vector on the right wing causing the aircraft to quickly roll to the left. Fortunatly the first officer was quick to react and input the right aileron and left rudder to keep the aircraft under control as it was slowly climbing away from the runway.
It happened after the aircraft had passed V1, the decision speed rejecting the takeoff was now not an option. From this point it was all about keeping the aircraft flying and figuring out what was going on. Now the forward engine mount support couldn't handle the kind of forces it was being subjected to. The outboard cone bolt sheared off as it wsa designed to do but the inboard one didn't have tim to do so which had the consequence that the engine just tore off. It tore off all the hydraulic and fuel lines. It leds to a gaping hole in the wing where it used to be mounted. One passenger saw the whole thing unfold which in realitiy took only a few seconds Pilots heard a huge bang as the engine separated but a few seconds later a strange tearing sound and a suddent jolt of bank, this time to the right. After that the aircraft finally started to handle more like the way that the pilots had been trained it would after a normal engine failure. The captain brought the land gear up and started troubleshooting the issue Immediate indications they had available was the retarded thrust lever 0 or decreasing engine indications on engine number 2 plus a thrust reversive warning on the same engine. As well as low pressure warnings from the associatied engine driven hydraulic pump. All of this minus the thrust lever indication were clear signs of some kind of engine failure on number 2 engine. but both pilots were careful not to draw any quick conclusions at this point. Because this failure had so far not acted like any other failure they have seen or practiced on the simulator, They were aware of the misidentification that happened to the pilots of British Midlands Flight 092 who, after similar indications, had shot down the wrong engine back in 1989. They didn't want to do the same mistakes so at several hundreds feet of alttiude, the captain went through all indications and came to the conclusion they suffered some severe damage in engine 2.
DISAPPEARING Engine! The Incredible story of Nationwide 723
In the plane, there are 4 cabin crew and 2 pilots. Marilyn Rink was the cabin controller, one of the most experienced cabin crew member of the airline. The captain was the 50 years old Trevor Arnold, experienced pilot with 13 860 hours at the time of the flight including 3 277 hours on the Boeing 737 - 200. He started flying for Nationwide back in 1997 and had been been during a few years flying for other operators until 2006 when he came back again. By contrast, his first officer was Daniel Perry , 25 years old He was brand new on this job, starting flying for Nationwide only 1 month before this flight with a total flying hours of 1 000 hours only including 278 hours on the type which he had gotten his type rating on earlier that same year. Captain was skilled operator and a stickler for following rules and standard operating procedures. For the first officer it was probbaly a good new because the less experienced you are, the more important it's that everyone follows procedures. That's the only thing you have to hold on into until your experience builds up. Pre flight briefing was okay. Just light rain in Cape Town, northerly winds and a layer of clouds. The plane was part of the very first variance of the 737 family called " The Originals ". Most of us just refer to them as " The Jurassics ". Thie aircraft handled just like a sport car. This particular 737 - 200 advanced model first came out in 1971 and it was equipped with slightly more powerful Pratt and Whitney JT8D-15 engines, improved aerodynamics auto brakes and a higher fuel capacity compared to the original 200 giving it a better range and overall efficiency. The 2 engines were low bypass ratio turbofan engines, making them long and thin.
They were used because when Boeing were designing the original 737 they wanted an aircraft that would have a low ground clearance so they could be easy to work on for ground handlers since Boeing assumed that it would mainly operate into smaller airports where the facilities might not be that great. This meant that the engines were mounted directly onto the wings without without any pylons. The engines were attached with 2 main mounts, one forward and one aft and thena secondary support assembly forward of tha aft engine mount behind. The engine supports are bolted onto the wing using cone bolts which are constructed to hold up for any normal loads that the engine might experience But if a strong enough force is applied to them, for eample if a gear up landing would happen, the bolts were designed to shear off and release the engines and therefore protect the wing and overall airplane main structure. It was very important that these bolts were mounted correctly with the exact amout of torque applied to them to avoid over stressing the bolts which could lead to metal fatigue. to avoid over stressing the bolts, which could lead to metal fatigue. This was a known issue especially on the older type of engine mouts that were fitted to this particular aircraft. So the FAA issued an airworthiness directive several years earlier outlining strict inspection intervals to be done at least every 700 cycles of these mounts and bolts.
At the time of the accident, Nationwide were operating 11 Boeing 737 - 200s. They were doing all their maintenance in house in their own maintenance organization But prior to 2007 the organization faced some problems. Key management personnel most often the quality manager ended up quitting their jobs just prior to the renewal audits of the Air Maintenance Organization or AMO approval. Because the audits always highlightened several non compliances with existing rules and regulations Most of these findings were never properly addressed or closed which is why, like unbeknown to the pilots, the AMO was lacking a formal license to operate at the time of the accident. The maintenance work continued to be done based on an unofficial mail sent from the South African Civil Aviation authorities allowing them to continue for now. But there didn't exist any provisions for such an extension. One of the findings that were later revealed was that the accident aircraft didn't have any records of any inspections of the engine mounts for the previous 5 years prior to the accident. Pilots were unaware of this. Only thing pilots can do is to verify that all documentation is available and that all applicable certification dates are in date and obviously that the aircraft looks good during the walkaround. The plane was taking off, soon reaching the high speed regime of the takeoff from which is a rejected takeoff is only executed if an engine failure, fire, or a predictive windshear warning is heard, or if the runway is blocked or the aircraft is unsafe or unable to fly. Reason pilots only reject for those things above 80 knots is because it's normally safer from that position to take the aircraft into the air and deal with whatever problem you might have when you are already airborne. This will give more time to think and troubleshoot and pilots will then have the full use of the whole runway for landing if you then decide to come back.
Aircraft would have used a lot of runway accelerating up to this point. And the speed would be relatively high so even though it would be possible the stop the aircraft safely all the way up to the decision speed of V1. It would likely be safer and better to just bring any minor problem into the air. That's what pilots call being go minded. Most airlines adopted this philosophy today. Just before the plane took off, something went wrong on the right wing when the aft cone bolt which was holding the engine in place had developed a small fatigue crack and during the rotation, the crack suddently gave away and the bolt fractured. In normal conditions, the secondary engine support assembly is supposed to be able to hold the load if the aft mounts fails. But this secondary support also failed. Secondary support was never found after the accident so we don't know what happened. Either it also broke from the strain or as some newspapers reported after the accident, it might not have been fitted at all after the last engine overhaul. Anyway now nothing was holding the back part of the engine in place while it was still producing full takeoff thrust. This basically transformed the forward engine mount into a pivot point around which the engine could move. The consequence was that now the engine started to swing forward and upwards. Since the thrust levers were mechanically connected via a control wire to the engine, this wire was now pulled back with the full force of the departed engine which caused the right engine thrust lever in the cockpit to whisk backyard and slam into the pedestal so hard that it left a deep indentation to it. Other consequence was the right engine started producing an upward thrust vector on the right wing causing the aircraft to quickly roll to the left. Fortunatly the first officer was quick to react and input the right aileron and left rudder to keep the aircraft under control as it was slowly climbing away from the runway.
It happened after the aircraft had passed V1, the decision speed rejecting the takeoff was now not an option. From this point it was all about keeping the aircraft flying and figuring out what was going on. Now the forward engine mount support couldn't handle the kind of forces it was being subjected to. The outboard cone bolt sheared off as it wsa designed to do but the inboard one didn't have tim to do so which had the consequence that the engine just tore off. It tore off all the hydraulic and fuel lines. It leds to a gaping hole in the wing where it used to be mounted. One passenger saw the whole thing unfold which in realitiy took only a few seconds Pilots heard a huge bang as the engine separated but a few seconds later a strange tearing sound and a suddent jolt of bank, this time to the right. After that the aircraft finally started to handle more like the way that the pilots had been trained it would after a normal engine failure. The captain brought the land gear up and started troubleshooting the issue Immediate indications they had available was the retarded thrust lever 0 or decreasing engine indications on engine number 2 plus a thrust reversive warning on the same engine. As well as low pressure warnings from the associatied engine driven hydraulic pump. All of this minus the thrust lever indication were clear signs of some kind of engine failure on number 2 engine. but both pilots were careful not to draw any quick conclusions at this point. Because this failure had so far not acted like any other failure they have seen or practiced on the simulator, They were aware of the misidentification that happened to the pilots of British Midlands Flight 092 who, after similar indications, had shot down the wrong engine back in 1989. They didn't want to do the same mistakes so at several hundreds feet of alttiude, the captain went through all indications and came to the conclusion they suffered some severe damage in engine 2.
Post.
First officer needed to push substancial amount of left rudder to keep the aircraft going straight, due to the asymmetric thrust that was being produced, agreed to the diagnosis. In case of a severe engine damage, the Boeing 737 non normal checklist contains something known as memory items, items that pilots need to do from memory as quickly as they can due to the critical nature of the items. In this case the first officer would have called for the memory items to be completed and the captain would then have called them out for confirmation and the captain would have then called them out for confirmation before doing them to make sure its first officer agreed with the actions. He would have start with " Thrust lever, engine number 2. Confirm close? " First officer would look down confirming he was about to move the correct thrust lever and then called " Confirmed. " Captain would have closed it. In this case the thrust lever was already very closed. Next came " Engine start lever, engine number 2. Confirm cutoff? " " Confirmed. Cutoff. " " Engine fire warning switch, engine number 2. Confirm pull? " " Confirmed. Pulled. " All these memory items were designed to secure the engine down by shutting off the access to fuel and hydraulic fuels to the damaged engine. The last memory item was to rotate was to rotate the engine fire warning switch to release the fire extinguishers into the engine in case it was on fire. That was not the case here. Rest of the checklist could wait until the aircraft was established above the minimum sector altitude. Pilots could focus on climbing and retract the flaps. The smoke trailing the right wing was a mist of hydrualic fluid and fuel which was vented out into the air. Memory items were supposed to stop the fuel and hydraulics from reaching the engine. In this case the lines have been ruptured in board of the shut off values that were designed to do this job. So fuel and hydraulic fluid was gushing out from the supply lines.
Meanwhile control tower witnessed what happened and pressed the crash button to alert the firefighters because of the risk of crash. He then also realized that there was another aircraft that he cleared landing for as Nationwide flight was departing. He advised the crew on possible debris on the runway but didn't advise them to go around. It landed and after that the pilots of this plane confirmed to the tower that there were a lot of debris around the center line towards the last third of the runway. Captain Arnold heared this transmission on flight 723. He called a mayday, assessing that they were having thrust issues on the right engine and also hydraulic issues He asked if it was possible to clear the runway from those debris during the 15 / 20 minutes they would take to come back to the airport. Firefighters and rescue personnel were already standing at the edge of the runway. With all other available personnel of the airport they worked on moving away the rubble to the side of the runway. All the aircraft going to the airport were now diverted to George airport instead. Soon only Nationwide Flight 723 was flying in this airspace. Crew purser Marilyn was called into the cockpit and captain Arnold asked her to go through the cabin and have a look to give the pilots a damage report. She then informed that parts of the right engine was missing. In fact she knew that the whole engine was gone but she later said that she didn't want to worry the pilots too much. In a situation like this there is no such thing as too much information. It was better for the information to be the most accurate as possible. to plan course of action. In this case luckily it wouldn't have make any difference. Passengers were prepared now for an emergency landing. In case of a problem like this, several emergency checklists need to be completed.
In this case the crew would have started with completing the engine fire, severe damage or reparation checklist which starts out with the memory items and then continue by in a systematic manner, making sure that the aircraft is as safe as possible in this new configuration. This includes things like setting up the air conditionning system, to not use bleed air from the damaged engine, starting up the APU and crucially, balancing the fuel as the fuel would only be used from 1 tank in this situation. That can lead ao a substancial fuel imbalance wich can come with handling issues. In this case they should not try to correct the imbalance issue because if only the left engine is working, therefore only feeding fuel from the left tank that tank should be lower on fuel. If the right tank is lower, that's a clear indication of fuel leak. If they try to correct the imbalance here, they transfer precious fiel out through a gaping hole on that side. Unfortuantly the crew didn't think about that. On top of this due to the leaking hydrualic lines, the hydraulic pressure was quickly dropping. Captain showed great sign of humility and airmanship when he gave back the controls to the first officer after the plane started yawing and pitching. A basic system using radio altimeter combined with the aircraft's configuration to issue warnings were here back then. Problem is that terrain warnings might come very late as it's only reactive and not predictive like later versions are. To fly a single engine approach the crew would have used the one engine inoperative landing checklist which told them to prepare for flaps 15 landing. That meant they would land at higher speed than normal but also with less drag in case of a go around. Higher speed also meant better aerodynamic efficiency from the rudder which was needed due to the asymmetric thrust they were experiencing. First officer Perry needed to use almost full left rudder to help the aircraft going straight.
A go around method approach was not great considering fuel loss, hydraulic issues and weather reports indicating that visibility was getting worse with lower clouds drifting from False Bay. They lined up with the ILS approach.
First officer needed to push substancial amount of left rudder to keep the aircraft going straight, due to the asymmetric thrust that was being produced, agreed to the diagnosis. In case of a severe engine damage, the Boeing 737 non normal checklist contains something known as memory items, items that pilots need to do from memory as quickly as they can due to the critical nature of the items. In this case the first officer would have called for the memory items to be completed and the captain would then have called them out for confirmation and the captain would have then called them out for confirmation before doing them to make sure its first officer agreed with the actions. He would have start with " Thrust lever, engine number 2. Confirm close? " First officer would look down confirming he was about to move the correct thrust lever and then called " Confirmed. " Captain would have closed it. In this case the thrust lever was already very closed. Next came " Engine start lever, engine number 2. Confirm cutoff? " " Confirmed. Cutoff. " " Engine fire warning switch, engine number 2. Confirm pull? " " Confirmed. Pulled. " All these memory items were designed to secure the engine down by shutting off the access to fuel and hydraulic fuels to the damaged engine. The last memory item was to rotate was to rotate the engine fire warning switch to release the fire extinguishers into the engine in case it was on fire. That was not the case here. Rest of the checklist could wait until the aircraft was established above the minimum sector altitude. Pilots could focus on climbing and retract the flaps. The smoke trailing the right wing was a mist of hydrualic fluid and fuel which was vented out into the air. Memory items were supposed to stop the fuel and hydraulics from reaching the engine. In this case the lines have been ruptured in board of the shut off values that were designed to do this job. So fuel and hydraulic fluid was gushing out from the supply lines.
Meanwhile control tower witnessed what happened and pressed the crash button to alert the firefighters because of the risk of crash. He then also realized that there was another aircraft that he cleared landing for as Nationwide flight was departing. He advised the crew on possible debris on the runway but didn't advise them to go around. It landed and after that the pilots of this plane confirmed to the tower that there were a lot of debris around the center line towards the last third of the runway. Captain Arnold heared this transmission on flight 723. He called a mayday, assessing that they were having thrust issues on the right engine and also hydraulic issues He asked if it was possible to clear the runway from those debris during the 15 / 20 minutes they would take to come back to the airport. Firefighters and rescue personnel were already standing at the edge of the runway. With all other available personnel of the airport they worked on moving away the rubble to the side of the runway. All the aircraft going to the airport were now diverted to George airport instead. Soon only Nationwide Flight 723 was flying in this airspace. Crew purser Marilyn was called into the cockpit and captain Arnold asked her to go through the cabin and have a look to give the pilots a damage report. She then informed that parts of the right engine was missing. In fact she knew that the whole engine was gone but she later said that she didn't want to worry the pilots too much. In a situation like this there is no such thing as too much information. It was better for the information to be the most accurate as possible. to plan course of action. In this case luckily it wouldn't have make any difference. Passengers were prepared now for an emergency landing. In case of a problem like this, several emergency checklists need to be completed.
In this case the crew would have started with completing the engine fire, severe damage or reparation checklist which starts out with the memory items and then continue by in a systematic manner, making sure that the aircraft is as safe as possible in this new configuration. This includes things like setting up the air conditionning system, to not use bleed air from the damaged engine, starting up the APU and crucially, balancing the fuel as the fuel would only be used from 1 tank in this situation. That can lead ao a substancial fuel imbalance wich can come with handling issues. In this case they should not try to correct the imbalance issue because if only the left engine is working, therefore only feeding fuel from the left tank that tank should be lower on fuel. If the right tank is lower, that's a clear indication of fuel leak. If they try to correct the imbalance here, they transfer precious fiel out through a gaping hole on that side. Unfortuantly the crew didn't think about that. On top of this due to the leaking hydrualic lines, the hydraulic pressure was quickly dropping. Captain showed great sign of humility and airmanship when he gave back the controls to the first officer after the plane started yawing and pitching. A basic system using radio altimeter combined with the aircraft's configuration to issue warnings were here back then. Problem is that terrain warnings might come very late as it's only reactive and not predictive like later versions are. To fly a single engine approach the crew would have used the one engine inoperative landing checklist which told them to prepare for flaps 15 landing. That meant they would land at higher speed than normal but also with less drag in case of a go around. Higher speed also meant better aerodynamic efficiency from the rudder which was needed due to the asymmetric thrust they were experiencing. First officer Perry needed to use almost full left rudder to help the aircraft going straight.
A go around method approach was not great considering fuel loss, hydraulic issues and weather reports indicating that visibility was getting worse with lower clouds drifting from False Bay. They lined up with the ILS approach.
Post.
They didn't stand a chance - Bhoja flight 213
On evening of April 20th 2012, 121 passengers and 6 crew boarded on Boeing 737 at Karachi in Pakistan. Flight 213 was being operated Bhoja Air and being the airline inaugural for Karachi to Islamabad, it was expected to take 2 hours. Over Islamabad, storms were brewing, creating conditions which the 2 pilots were not remotely trained to deal with. These pilots were so poorly trained that they hadn't even be taught how to fly this particular aircraft, a Boeing 737 200. All of their training and the manual on board were from an older version of the plane. That version had a much less sophisticated autopilot and other less advanced systems. They just knew that this plane was a bit more high tech but they weren't trained on the details of this newer technology. So they overestimated the aircraft's capabilities. The pilots were 58 years old captain Noorullah Khan Afridi and 53 years old Javaid Malik, the first officer. The captain was a former Air Force pilot with over 10 000 hours of flying experience. He had been flying 737 for several years with a different airline before switching to Bhoja earlier that year. The first officer was also a former Air Force pilot althought he was less experienced with 3 000 hours of flying experience. He worked for the same airline as the captain has worked previously and followed him over Bhoj air once he switched. The 2 pilots were friends and had been paired together for more than half of the flights they had flown with the new airline so far. The captain would make a serie of bad decisions on their approach to Islamabad. Despite the pilots overall experience, they each had only 80 hours on this specific version of the 737 200. The captain previously began training on a more modern version of the 737 at his last airline, but his training was discontinude after his supervisors deemed him unable to operate the automated fligth deck in a safe and efficient manner.
At first, the plane followed its route normally. But the aircraft they were flying on shouldn't have been allowed to carry passengers. That's because as far as Pakistan's civil aviation authority was concerned, Bhoja didn't have any advanced version of the 737. 200. They thought this fleet consisted solely of the base model 737. Indeed, Bhoja airline pilots training program reflected this. Pilots were only trained to fly the base model 737 200 and not the advanced version. It wasn't that the civil aviation authority didn't know this. In fact, they allowed Bhoja to operate this particular plane even though they hadn't granted its certificate of airworthiness to carry passengers. It also would later be claimed that senior officials at the airline had engaged with deals with the civil aviation authority, aka the CAA, to allow the airline to operate in the first place. It was about corruption. The Swiss Cheese model by psychologist James Pearson is often used to explain aircraft accidents. The diea goes that accidents when layers of safety represented here by the cheese slices have holes in them, which on some unfortunate occasions line up in such aa way as to allow an accident to happen. Naturally, the way to prevent similar accidents in the future is to add more layers of safety and to close up some of the holes. At the Bhoja company, the holes were numerous and big. The burreacrats and businessmen who arranged the state of affairs were not on the board of flight 213. Pilots could see on their radar that powerful storms were building in front of them.The storm at Islamabad was significant, with thunder and lightning, heavy rain and strong winds. The closer they got, the more the pilots saw how intense it was. Since the weather at their first alternate airport, at Lahore, was bad, the first officer suggested to check the weather on Pechawar, their second alternate airport. The captian dismissed this idea. Pilots are supposed to trust their instruments and not fate.
The first officer didn't question the captain who was like a mentor for him. The flight continud descending into the murky weather surroudning Islamabad. Ahead of the plane, the pilots could see what is known as a squall line, a serie of storms stretching across a long distance. One the other side of the squall line, lay the airport.
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They didn't stand a chance - Bhoja flight 213
On evening of April 20th 2012, 121 passengers and 6 crew boarded on Boeing 737 at Karachi in Pakistan. Flight 213 was being operated Bhoja Air and being the airline inaugural for Karachi to Islamabad, it was expected to take 2 hours. Over Islamabad, storms were brewing, creating conditions which the 2 pilots were not remotely trained to deal with. These pilots were so poorly trained that they hadn't even be taught how to fly this particular aircraft, a Boeing 737 200. All of their training and the manual on board were from an older version of the plane. That version had a much less sophisticated autopilot and other less advanced systems. They just knew that this plane was a bit more high tech but they weren't trained on the details of this newer technology. So they overestimated the aircraft's capabilities. The pilots were 58 years old captain Noorullah Khan Afridi and 53 years old Javaid Malik, the first officer. The captain was a former Air Force pilot with over 10 000 hours of flying experience. He had been flying 737 for several years with a different airline before switching to Bhoja earlier that year. The first officer was also a former Air Force pilot althought he was less experienced with 3 000 hours of flying experience. He worked for the same airline as the captain has worked previously and followed him over Bhoj air once he switched. The 2 pilots were friends and had been paired together for more than half of the flights they had flown with the new airline so far. The captain would make a serie of bad decisions on their approach to Islamabad. Despite the pilots overall experience, they each had only 80 hours on this specific version of the 737 200. The captain previously began training on a more modern version of the 737 at his last airline, but his training was discontinude after his supervisors deemed him unable to operate the automated fligth deck in a safe and efficient manner.
At first, the plane followed its route normally. But the aircraft they were flying on shouldn't have been allowed to carry passengers. That's because as far as Pakistan's civil aviation authority was concerned, Bhoja didn't have any advanced version of the 737. 200. They thought this fleet consisted solely of the base model 737. Indeed, Bhoja airline pilots training program reflected this. Pilots were only trained to fly the base model 737 200 and not the advanced version. It wasn't that the civil aviation authority didn't know this. In fact, they allowed Bhoja to operate this particular plane even though they hadn't granted its certificate of airworthiness to carry passengers. It also would later be claimed that senior officials at the airline had engaged with deals with the civil aviation authority, aka the CAA, to allow the airline to operate in the first place. It was about corruption. The Swiss Cheese model by psychologist James Pearson is often used to explain aircraft accidents. The diea goes that accidents when layers of safety represented here by the cheese slices have holes in them, which on some unfortunate occasions line up in such aa way as to allow an accident to happen. Naturally, the way to prevent similar accidents in the future is to add more layers of safety and to close up some of the holes. At the Bhoja company, the holes were numerous and big. The burreacrats and businessmen who arranged the state of affairs were not on the board of flight 213. Pilots could see on their radar that powerful storms were building in front of them.The storm at Islamabad was significant, with thunder and lightning, heavy rain and strong winds. The closer they got, the more the pilots saw how intense it was. Since the weather at their first alternate airport, at Lahore, was bad, the first officer suggested to check the weather on Pechawar, their second alternate airport. The captian dismissed this idea. Pilots are supposed to trust their instruments and not fate.
The first officer didn't question the captain who was like a mentor for him. The flight continud descending into the murky weather surroudning Islamabad. Ahead of the plane, the pilots could see what is known as a squall line, a serie of storms stretching across a long distance. One the other side of the squall line, lay the airport.
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