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- - Luxair F50 Crash: Pilot's Fault (http://www.pprune.org/forums/showthread.php?t=108985 )

willbav8r 25th November 2003 14:27

Never argue with a fool - he will bring you down to his level and beat you with experience...........

flt_lt_w_mitty 25th November 2003 14:35

Never-the-less, Willb, you have to admit it is A bad conbination for a yourger guy, especially :cool:

ATC Watcher 25th November 2003 16:22

I was told this afternoon that the final report will be released on Dec 15. Those who have seen the
latest version say its current conclusions are rather direct and very critical to both the pilots and
the airline.
wait and see.:(

spuis 26th November 2003 06:45

beta rabge selection

Hi,

Looking through the report, I'm still wondering what the position of the power levers was during
the last part of the approach.
I can't seem to find whether the levers were in flight idle, or below that.
This is a rather important part, since there is also a mechanical lock on the levers preventing
inadvertent selection of power below flight idle.
Did the props go into beta range at gear down selection because the mechanical lock was lifted,
and the (non-modified) anti-skid system signalled spin-up? Or was there a fault in the Power lever
angle measering as well?

Spuis

P.S. 4000 hours for a turboprop captain doesn't seem inexperienced to me.

alf5071h 26th November 2003 12:31

Spuis
There doesn’t seem to be any data for power lever angle on the FDR. However the propeller low
pitch parameter indicates that the beta mode was engaged (or available?) for approximately 16
secs; this appears to be coincident with gear lowering, the reason given in the report.

Thus as your post suggests the mechanical lock was lifted and the secondary device was not
available due to some other cause yet to be determined. I assume it to be normal practice for the
crew to select flight idle, relying on the mechanical lock to prevent beta range in the air. The crew
may or may not have been aware of the design weakness that lifts the lock for 16 secs with gear
lowering. If the crew believed that the aircraft was modified then the need for awareness during
gear lowering was not required. There does not appear to be any evidence that the crew lifted the
lock; I could accept that the timing of the low pitch indication with the gear down is circumstantial,
but the engine parameters indicated idle, descent was commenced, and flap selected much earlier,
thus I hope that the logical conclusion ties the lock to the gear.

Some crew may have detected that the power levers were displaced further rearward than usual, I
do not know what the physical dimension is, but many crews in high workload situations have
missed similar cues and also ‘forget’ any awareness of design weakness if applicable. Thus at best
it may be concluded that the crew were unwise to continue the approach with changing
circumstances, but I suspect that there are some of us who have done something similar, and
probably all of us wish that we had the wisdom of hindsight after poor judgment.

spuis 28th November 2003 09:31

ALF5071h,

What I was aiming at is the following:

Were the power levers selected below flight idle (thus lifting the mechanical stop, or it being
broken), or was there a fault in the PLA pick-up (sensing ground idle with power levers actually
being in flight idle.

On the F50 the range from flight to ground idle is approx. 3-4 cm.
We will just have to wait for the entire report.

Spuis

ortotrotel 2nd December 2003 23:19

When 411a talks about experience, I actually concur with his philosophy. While 2800 hrs TOT is
not to be sneezed at, his total time and age would suggest that he has not faced a diverse range
of operational conditions and experiences, from which maturity evolves.

Being experienced in a narrow spectrum of the industry can lull a driver with lots of TOT into a
false sense of accomplishment.

411 sounds (like any pilot who has bent a little metal...) as though he values this diversity in work
experience to make calculated risk-assessments - but not in a rushed context. This is an error
commonly made by "inexperienced" pilots.

I will expect this to be a causal contribution to the accident.

The Canadian MOT encourages us to learn from the mistakes of others, as we probably won't live
long enough to make them all ourselves...

RatherBeFlying 3rd December 2003 09:30

16 seconds at Flight Idle, not Beta

Spuis, As I mentioned before, the preliminary report shows the crew reduced power to 0% torque
and did not encounter prop pitch below 10 degrees for 16 seconds until the gear began coming
down.

Once the first prop went into low pitch, they were in the air for only another 11 seconds if one
takes the end of the CVR as time of impact.

alf5071h 3rd December 2003 17:40

ortotrotel

Whilst not disagreeing with your observations on total hours and experience, it would be
disappointing for ‘inexperience’ to be given a contributing factor in this or any accident.

At some stage in our flying careers we have been or still are, inexperienced. Thus taking your point
to the extreme then all of us may contribute to an accident; that contribution I suggest is not one
of inexperience, but of human error.

Inexperienced pilots, either by low hours or by less exposure to a range of situations may make
different mistakes from those made by the more experienced pilots. We all make mistakes; it is
more likely to be the way that the more experienced pilots mitigate their errors or recover from
mistakes that prevents their accidents. Thus the problem for the industry to solve is how to provide
the less experienced crews with error detection, mitigation, and recovery techniques. Whilst
previously this was seen to be airmanship, regrettably today it requires more rules and procedures
with the associated loss of flexibility.

The accident investigation needs to identify the specific errors that contributed to this accident and
the causes of the errors.
Quote:

“There are no such things as accidents. What we call an accident is the effect of some
cause which we did not see” - after Voltaire

alf5071h 12th December 2003 14:35

Re Safetypee’s request for a web link to the Turboprop version of the PSM+ICR training guide. I
cannot find any link via the FAA or CAA, but the following key documents are posted at this site;
Turboprop PSM+ICR

PSM+ICR report summary.pdf

engine types.pdf
propeller fundamentals.pdf
asymmetric flight.pdf
simulating engine failure.pdf

I suggest 'right click' and 'Save Target as' for downloads.

My 737 12th December 2003 18:37

Nov 6th 2002,

A sad day for everyone, the final report can be found here.

Final Report.

Let those who lost lives and their families rest in peace.
We can all learn from this, find better ways and try prevent series of events like these happening.

Brgds.

Superpilut 13th December 2003 08:14

And if you want to have the additional 114 pages of annexes look here: Report Annexes

PropsAreForBoats 13th December 2003 10:36

Quote from the final report:

Quote:

Not withstanding the existing recommendations and procedures, it appears that intentional
override of the primary flight idle stop on turboprops in flight is not excluded.

The existing design of the Fokker 27 Mk050 does not prevent the selection in flight of the
propeller pitch setting below the flight idle regime.

This is in my opinion an important lesson from this accident, and something all pilots of the Fk50
and similar turboprops should review.

alf5071h 17th December 2003 15:26

The complete failure of a safety management system.

I am pleased to see that the very comprehensive final report addresses several human factors
issues that contributed to the accident. The report identifies blatant errors and places them in
context of an operational accident; unfortunately this was not an operational accident and thus the
investigation has chosen an inappropriate primary cause. There is also a short fall in the human
factors investigation by failing to give an understanding, or at least a theory, as to why the crew
shut down both engines.

The report gives the primary cause of the accident thus: (my italics, assuming ‘initial’ means
primary from the translation)
Quote:

The initial (primary) cause of the accident was the acceptance by the crew of the approach
clearance although they were not prepared to it, namely the absence of preparation of a
go-around. It led the crew to perform a series of improvised actions that ended in the
prohibited override of the primary stop on the power levers.

Even with the care shown in this report why do investigators in general fall back on the operating
crew for being the primary cause of an accident?

This crew was the unfortunate (possibly deficient), last link in the error chain. This accident was
waiting to happen; any one of a number of previous crews who, if they too had violated the flight
idle restriction (which may have been common practice) during the critical 16 secs during gear
selection at low altitude may have lost control. It would at best be speculative to suggest that any
other crew would have handled the unique flight characteristics resulting from full in-flight reverse
and the associated confusing engine displays in any better way than did the accident crew.

Thus the primary cause from an engineering perspective could have been stated as the loss of
control due to both engines giving reverse thrust or a combination of reverse and engine
shutdown.

Yet in reality the primary cause was the complete failure of the safety management system, from
the authority at one extreme to individual crew at the other. The safety system was riddled with
assumptions, allowed violating behavior by both individuals and organisation, and lacked the use of
error checking or mitigating techniques.

The aircraft crashed because the right engine remained in reverse, the left engine was shut down,
and then the right engine was shut down. The failure to explain or present a theory as to why the
crew shut down both engines deprives the industry of further understanding human error. (I
accept the difficulties due to lack of recorded data).

As the result of assumption, error, personal failing, and many other reported circumstances, both
engines were in reverse in the air. The crew sensed that something was abnormal (seat of the
pants), deceleration, pitch down. They certainly heard abnormalities in prop speed (probably the
dominant cue) and had confusing engine indications: very high prop rpm, increasing engine speed
with flight idle selected. The crew apparently detected the error, the recovery action was
unsuccessful (right engine remained in reverse).

Immediately prior to engine shutdown the crew would have had a gross thrust abnormality, the
right engine remained in reverse, but the left was recovering to give positive thrust, thus the crew
might have been expected to detect a right hand engine failure (dead leg dead engine from rudder
input), but why was the left engine was shut down first, and then later the right?

The engine indications were split, the left engine had lower values than the right; there was no
evidence that the crew detected an engine failure or called for shut down drills. Thus was the left
engine shutdown by mistake?

The problem was compounded by the short time period; was the right engine shut down because
of prop over speed - the failure to recover from beta range. Then why shut down both engines,
was each engine was shut down by different crew members? It is the details of these actions that
are the key factors that led to the crash.

If both propellers had been recovered to normal flight range then the aircraft may well have
continued in a flyable condition i.e. the accident would not have happened; yet this issue is not
included in the discussion, or the reason for the right propeller failing to recover from beta range
(except in appendix 22). A recommendation should be at least to brief crews that having entered
beta range if they then required full power (baulked landing) the power levers should only be
moved forward carefully avoiding slamming to the forward stop.

The answers to the human factor issues could reside in the training programs, in previous / basic
training, or other experiences including firewalling power levers or rushing engine shutdown, but
these aspects were not investigated in depth. For generic information see the the full PSM+ICR
report ;human factors issues at 4.2.12 and section 8; ops issues at 4.2.11; training at 7.2 and
7.2.4.

This accident is a lesson for all who think that by passing one defense (flight idle stop) with
reliance on another, that they will not be exposed to risk. Whatever the aircraft or engine type,
always stay within the limitation of the AFM.

This was a tragic accident that matched most if not all issues that were identified by the PSM+ICR
project report. Also the background and the circumstances have been described previously by J
Reason in “Human Error” and “Managing the Risks of Organizational Accidents”; unworthy epitaphs
for those who lost their lives.
safetypee 18th December 2003 11:42

Unions oppose FDM

Flight International reports that the unions oppose the introduction of Flight Data Monitoring
(accident report recommendation). Why does the union, the flight crews themselves, have
objections to the use of a modern safety aid? Don’t they realize that it is their own interest –
improved safety?

If they don’t like FDM, then use LOSA; the crews could run that system themselves in a modified
form. Use of LOSA could have identified some of the errors in the F50 accident in time to have
prevented it.

Cfretland 18th December 2003 16:03

411A brings up an interesting issue regarding pilot experience. The European philosophy is a little
different when it comes to pilot hiering procedures. If you have 300 TT and can pass the VERY
important two day aptitude tests/IQ tests, then you have what it takes. They really don't
emphesise to much on flight experience, because you will be TRAINED.
The problem with this is that you will be placed in the right seat as a first officer. You are logging
several thousand hours of pilot time but everything is SIC time. We all know how easy it is sitting
in the right seat, not having to make any decisions and the decisions you do have to make are
always "overlooked" up by a captain.
Than one day you upgraded to captain with a lot of total time but perhaps only a few hundred PIC
and you are placed with a 300 hour co-pilot.....now suddenly YOU are the one in charge with
nobody to back up your actions.
In the USA things are a little different. There you gain valuable PIC expreience by flying
cargo/charter/flight instruction etc. There you learn to be in charge and gain captain experience
flying light singles/twins before meeting the airline requirements.
I just got hired flying EMB-145 with 2800 TT and 2600 PIC. Currently flying as captain(single pilot)
on King Air 200/100/90 and Navajos.
I have learned to make dicisions whitch in my humble opinion is the hard part....not the flying.

LEM 19th December 2003 10:45

I see the cause of this accident from this perspective:

we don't train our Captains to be Great Captains.

In the (very) old days, the Captain was capable of coming back after takeoff if he discovered his
preferred brand of whisky was not on board...

Ridicolous for nowadays standards, of course.

But it's on this trait of the character that I want to focus here.
The Captain was and felt like a God, the master of his world.

We all know the culture has changed a lot in the last decades, also because many accidents have
been attributed to this kind of behaviour, called machismo.

In Tenerife machismo caused the worst accident ever, right?

Hmmmmmmm... wait a minute.

Can't we say that if the American crew had been more macho, more capable of dominating their
environment, less afraid of hurting the controller's feelings, instead of worring all the time about
what was going on, they would have grabbed the mike and asked directly to KLM " Hey mate,
where the **** are you, be careful we're on the active runway behind you!" ?

What I' m trying to say is that too many Captains today are
weak individuals.
They really have a hard time resisting all the psycological pressures imposed by the system.

I remember when I was an ATR copilot in Europe, I was ashamed by the weaknesses too many
Captains demonstrated, even the experienced ones.
The commercial pressures have become so many in this exasperated competitive market, thet it's
very difficult to an individual who doesn't have balls to say NO .
Too many accidents have happened because the crew was incapable of saying NO.
Air Florida, dozens of others, and eventually, Luxembourg.

In this last tragedy, the captain was skilled and experienced, but obviously, a weak individual.
Didn't he know that making a detailed briefing before every approach is a must, and especially in
CAT II, didn't he know that checking the glideslope (alt vs distance) is a must , didn't he know
thet being fully configured with the landing cklist completed before 1000ft in CAT I is a
must ???????

Yes, he certainly knew all that.

Selecting reverse in flight was the last stupid action of a desperate individual.

Being strong is hard sometimes, we all know it, and that's where management and senior Captains
failed pathetically:
they failed to set an example in everyday operations, to forge young pilots to a certain character, a
character capable of saying loudly "Fu*k the schedule, fu*k the fuel consumption, fu*k
everybody, I am in command and that's the way I'll do it...".

Nor the Luxair captain nor the copilot had this strenght and ability behind them, and when they
accepted the approach clearance they accepted their death sentence.

I'd like to tell a little episode regarding myself, even if I'm a bit embarrassed for obvious reasons,
and also for my colleagues:
some months ago, during sim ckrides, our chief pilot put in the same scenario for every crew:
engine failure after go around and purposely too early approach clearance for the ILS, about 6
miles from threshold, while in the middle of abnormal cklist and stuff...
Well, after I replied firmly "Negative sir, we are not ready for the approach, we'll call you back
when ready in about 3 minutes", he bursted into applause sayind I had been the only one not to
fall in the trap (I can imagine what orrible mess followed for my colleagues when they closed to the
ILS with still a thousand things to do!).
Embarrassing to tell (no pilot could resist a sense of proudness after such words):O , but what I'm
trying to say is: why the hell the others had no force to say NO?

I was fortunate enough to have a strong model, a quite rude Captain who was famous for his bad
character, but was definitely a great individual: my father.

The F50 captain also had a Captain father, but certainly of a different nature...

I'm glad he and his son survived the crash, to live forever in shame for those who lost their
relatives. :yuk:

LEM

KmarK 22nd December 2003 12:20

Safetypee
For info, Flight International only states what Management said, which is not really the truth. FDM
is in use in Luxair for about a year already (737 and E145 fleets).

unwiseowl 22nd December 2003 17:30

Nice post LEM, agree 100%.

safetypee 23rd December 2003 04:35

Flight Data Monitoring

KmarK, but another quote was that although data gathering was in use on the 737 and E145
aircraft, the data was not looked at i.e. no monitoring; thus, FDM as a safety tool was not in use.

The use of FDM would not have prevented this accident. There is nothing in the crash FDR data
that would have shown the human errors that occurred. Right up to the last piece of data the crash
may have been avoided; the loss of FDR data was due to both engines being shut down as was the
cause of the accident.

FDRs do not answer why a crew would shut down two engines. An alternative LOSA programme
might have detected previous instances of less than ideal CRM, rushed procedures, and deliberate
or inadvertent lifting of the idle baulk. Detecting these behaviors and taking corrective action may
have avoided the accident.

sky330 23rd December 2003 11:15

I'll basically agree with you LEM,

As too often, I have seen captains unable too say NO, no to the rushed approach,or.. or, or even
no to the stupid rostering that are sometime the initial step on the dreaded path to a incident.

Must I confess, to my whole shame, that I have sometime been one of them? It's soo much easier
too yield that to fight everybody alone because nowadays safety seems an obscene word with
money the only motto.

But the
"I am in command and that's the way I'll do it..." attitude can easily backfire

Authoritarism should (in my opinon) be banned from the cockit with the weakness of character you
denonced.

All is a question of balance and circumstances,

Never said it was an easy job :O

ATC Watcher 23rd December 2003 11:26

very good post LEM. You are right about macho behaviour of the past and todays sometimes weak
capts .
Just a correction, In Tenefiffe, the Pan am capt did shout " we are still on the runway " or
something to that extend but the call was crossed with the TWR call to try to stop the KLM...

alf5071h 23rd December 2003 14:51

What the Captain really means

There is substance in what LEM states, but what the “Captain really means” is that we all require
airmanship and need to continuously improve our personal standards. However what about the
other crew members? There was an indication in this accident that the co-pilot did appreciate the
tight situation, but he was unable to break the Captain’s line of thinking, therefore co-pilots also
require additional training.

Try these as examples, taken from Capt (Dr) Bob Besco’s paper “PACE”.

Probing - for a better understanding.

Alerting - the Captain of the anomalies.
Challenging - the suitability of present strategy.
Emergency Warning - of critical and immediate dangers

Probing
Captain, I need to understand why we are flying like this.
Aren't you putting yourself into a corner and aiming to shoot yourself in the foot.

Alerting
Captain, it appears to me that we are on a course of action that is drastically reducing our safety
margins and is contrary to both your briefing and to company's SOPs.
It is my function and responsibility to protect your blind spots. I see you are about to walk off a
cliff.

Challenging
Captain, you are placing the passengers and aircraft in immediate danger. You must choose a
course of action that will reduce our unacceptably high risk levels.
You are about to self destruct. You have the equivalent of a very angry and armed bogey in your
six o'clock position. We are all about to get the civil aviation equivalent of a 20 mil enema.

Emergency
Captain, if you don't immediately increase our safety margins, it is my duty and responsibility to
immediately take over control of the airplane.
You, your airplane and every one on board are about to be dead meat. I choose not to join you. If
you don't immediately cease and desist, I will take the airplane away from you. I owe it to myself,
my family, our passengers, and our company to restore an adequate margin of safety.

The complete paper is here.

--------------------
Unless specifically authorized everything else is forbidden.

KmarK 24th December 2003 09:04

Safetypee
just to confirm, FDM is installed and is in use, but only on the 737 and E145 fleet. It is not installed
on the F50. The processing of the data is done, but since FDM has been introduced only about a
year ago, it is still not used to its full capacity.
That management pretends that the pilot union is against the introduction is a mere lie, as you can
see from my previous statements. The pilot union asked Management in summer to stop using
FDM, as there was a breach of confidence ( see Flight International this and last week), but
management did not comply with the request.
As to the reason of the crash, it was not the shutdown of the engines, but the propellers entering
beta range that started the fatal sequence. The shutdown, as part of the restart procedure, was
rather the attempt to find a way out of the fatal situation. (BTW from the FDR data I can see only
one engine (left) that was shut down).

safetypee 24th December 2003 15:33

Kmark thanks for the update on FDM.

I do not agree with your simplified assessment for the reason for the crash – the propellers
entering beta range. Both props did go into beta and the aircraft descended, but it appears that at
some point the left prop was recovered to the normal range (it was found to be in the feathered
position). The FDR stopped at approx 900 ft agl when both engines were stopped.

Thus, as a hypothesis, as we cannot be sure, the aircraft could still have been flown with the right
engine shut down and the left working normally. The airspeed remained high, thus there should
not have been a problem with control (Vmca/Vmcl). The flaps were retracted to reduce drag. The
unknown was if the left engine would have produced enough thrust to over come the drag of the
right prop in reverse.

I agree with ALF5071H’s post on 16 Dec. The report confirms that both engines had been shut
down, and if a shut down is the logical drill for an over speed, for which there is no evidence that
the crew detected or that a drill exists, then only the right engine should have been shut down,
certainly not both at 900 ft. No explanation was given in the report as to why both engines were
stopped.

For at least one engine this appears to be ICR after a crew induced PSM.

CR2 24th March 2004 21:59

Just found this

23-MAR-04 Strike threat at Luxair?

Luxair passengers could face disruption to flights if pilots and cabin crew vote in favour of strike
action. The Wort has learned that the LCGB union has initiated strike proceedings at Luxair, writing
to pilots and cabin crew asking about their readiness to go on strike. Union attempts to discuss
problem areas with the Luxair management have failed, and employee confidence in the
management has disappeared because of its behaviour after the Fokker 50 crash, according to the
Wort. The union also believes the management has destroyed the entire safety culture at Luxair.

Link

Frangible 25th March 2004 00:32

Call me naive, but why aren't F50 systems designed so that it is impossible to enter Beta range in
flight, e.g. impossible to do it unless a/c senses it is "on ground"?

I know of several Casa 212s which crashed because the Beta stops were malfunctioning, and when
crew throttled back on approach, it went into Beta range, and they were too low to recover. All
claims settled out of court though, and the problem was fixed without publicity.

tom de luxe 25th March 2004 07:42

Frangible:
Read the accident report - Luxair didn't implement on their F50s what Microsoft would call a
"security update", and thus the Captain of the flight could fiddle with the prop blade angles more
than was good for the aircraft (a/c was high and fast when cleared to land at LUX, to slow down
Capt. (PF) overrides safety dev., nothing happens at first but then prop blades go to ground idle
the moment the FO confirms "Gear down".:ouch: )

CR2:
Yeah, right, safety culture...
(though the sacking of the six pilots/management pilots nevertheless looks like a cover-your-
 :mad: exercise for the current managment to me)

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