Taiwan plane crash

Not the first time the “wrong” engine has been shut down by mistake, and unfortunately it probably won’t be the last either.

However thorough the training, and however experienced the crew, there is always the chance that human error will creep in. At least it seems they did identify their mistake and try to correct it, unfortunately they ran out of time/height/airspeed.

Let’s hope procedures and/or training etc are improved as a result. The accident was a tragedy, but it would be even worse if no good came of it in the longer term…

http://www.reuters.com/article/2015/07/02/us-taiwan-airplane-idUSKCN0PC05L20150702

Official confirmation that a good engine was shut down.

The test is not relevant to conclude that the pilots are non efficient It shld be conducted on other type and ideally with other companies flying the same type.
It could be the flight syllabus that is lacking somewhat or some awkward safety procedures.

We know that the avionic of the -600 is build on a commune architecture with that of the Airbus jets by EADS. That commonality might have breached some old rules in the Turbo prop world.

10 pilots failed the proficiency check.

http://www.nytimes.com/2015/02/12/world/asia/10-transasia-pilots-fail-emergency-proficiency-test.html?_r=1

Been following the thread on PPrune. It does seem likely these poor pilots shut down a healthy engine, then lost all thrust in the sick on.

The real heart breaker: Engine 1 was just about ready to go again when they entered their final stall. it was spooling up. Another 10 to 20 seconds maybe and this could have been a near miss.

There is the Hypo that poor drainage of fuel system (omissions / no time or quality carb) might have resulted in the engine stopping. Hence, the Pilots might have seen the No. 2 shutting off after it sputtered (see FDR graphs) and then right after that seen the same thing occurring on No. 1 The immediate reaction of a pilot would certainly be to reduce the gas on nbr1 to prevent another engine shut-off (what we see on the graphs).

Also, if the Chief pilot ordered its second to restart the malfunctioning engine (n°2), the co-pilot seated on the right seeing that the engine on his side was still turning (feathered but propeller still turning ) might have thought that his chief pilot was wrong. Hence the restart sequence of nbr2 during 50 seconds before the Crew chief realizes the error of his second.

[ATTACH=CONFIG]235160[/ATTACH]

[ATTACH=CONFIG]235161[/ATTACH]

The ATR72-600 IMA (Integrated Modular Avionics) is also derived from that of a jet (single action shut down in contrast with a two step for a turbo (feathering)). There might be something there to investigate.

The ATR 72–600 avionics suite is based on a latest-generation integrated modular avionics (IMA) concept certified for the Airbus A380 programme. IMA modules acquire and exchange data and can host multiple applications, and the modular architecture means that hardware and software can be developed independently. Compared with the shipsets for previous ATR aircraft, Thales has reduced the number of equipment items required, leading to significant gains in direct maintenance costs at the same time as optimising communication between the different systems.

Source:
Thales Group

That is so sad.

Recently sent to me by email ?????

Keith.

TransAsia GE235: Shutting down the wrong engine

By: David Learmount

London

Source: Flightglobal.com
This story is sourced from Flightglobal.com

4 hours ago

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

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

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

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

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

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

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

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

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

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

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

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

Somewhat true, engine #2 failed, crew switched off fuel to #1…

See http://pbs.twimg.com/media/B9JarHTIAAAgAy3.jpg

Thank you Blue. Really interesting.

The footage is reminiscent of the 1968 Farnborough Air Show of the Breguet Atlantique. I don’t know of any video available on the web but the pilot was demonstrating single engine low speed flying when he executed a turn into the dead engine, the wing on that side went down, the nose dropped and the aircraft piled into one of the black sheds with loss of life.

I’ve checked and there is pathe newsreel, and colour 8mm, footage of the aftermath but not the accident itself.

Thomas Wang, director of the Aviation Safety Council, said:
“The plane flashed a flame-out signal for one of the two engines at 10:53:28 when the plane climbed to an altitude of 1,200ft, triggering a warning,” AFP news agency quoted Mr Wang as saying.

“Then the other [left] engine was shut down manually. The pilot tried to restart the engines but to no avail.

“That means that during the flight’s final moments, neither engine had any thrust. We heard ‘Mayday’ at 10:54:35,” he added

http://www.bbc.co.uk/news/world-asia-31162351

Sounds like (yet) another f__k-up in identification of the problem and in-correct procedure in dealing with it. I guess another revision of cockpit instrumentation and procedure will be needed.

A simple first step would be – the engine switches are illuminated red, yellow or green. If the FADEC (+fuel system etc) is happy with that engine, then the switch for that engine is green. If the FADEC is questioning that engine, it is yellow. If the FADEC is not happy with the engine, its red.

At least it would be a first step to avoiding another balls up like this again.

<>

Thanks Paul.

If true is that a very long time after the incident?

Charlie….Aviate, navgate, communicate ….. identify and then sort the problem as far as you can, work out where you want to go (so far as you are able), then tell people your plans .

35 secs seems a long time, and probably felt like an eternity to the crew in some respects, as they were dealing with numerous warnings and a dead engine, but by the time they’d done the emrgency actions I bet it seemed to fly past (no pun intended).

Some reports suggest they may have mis-identified which engine had failed, and then shut down the second (“live”) engine in error – but data may also show that the second simply failed of its own accord sightly later than the first….

Data recorders and CVR analysis will no doubt explain what happenned.

From Flight Recorder, BOTH engines flamed out in 2 minutes after take off………..

Somewhat true, engine #2 failed, crew switched off fuel to #1…

See http://pbs.twimg.com/media/B9JarHTIAAAgAy3.jpg

And as reported the Mayday followed 35 seconds later. If true is that a very long time after the incident?

That’s what I said in post #12

From Flight Recorder, BOTH engines flamed out in 2 minutes after take off………..

From my experience flying the OV-10 I can see this as a well understood phenomenom. In the OV-10, the propwash over the wing at takeoff (low speed, high power) contributed about 40% of the lift. If you suddenly lost one engine for whatever reason the natural human tendency was to maintain or increase power on the other engine. The result is to lose almost half the lift on the bad side while generating max lift on the good side. Looks like the same effect here. Lose the left, keep power on to try to maintain flight, try to hold the nose up, slow and approach the stall, the right wing generates a roll because of the lift imbalance and over you go.

Not a problem with enough altitude to ease the pitch and keep airspeed until you stabilize for single engine flight, but low and slow is a killer.

Another example from YouTube if it attached properly… https://www.youtube.com/watch?v=oH5hs0B5Oks

Thanks for your testimony.

I had a similar opinion at first but tyhen watching the video two things made me swicth my mind toward the explanation above:
.1st: There is no sign of any yaw angle when the plane pass the building. At that slow speed, if only one engine was functioning it should be seen on the video given the angle of sight. I made the hypo that a fuel pump failure might have cut both engines (remember they just took-of)
.2nd: when the plane rolls 90deg, if there had been a trust assymetry with one engine at full power at the other dead and some rudder applied, th roll won’t have looked that much as axy symetric. It is noteworthy for me that the plane rolled around it’s axis and I can’t see anty reason for the pilot to have tried to keep manually the plane on that axis like an airshow pilot. IMOHO, this means that the plane had no trust on both side.

Best regards,

Tom

I was. There was a really stiff breeze blowing that day. I thought it played a part. As the aircraft commenced a turn to port into the dead engine the rising starboard wing caught the wind’s full force coming in from the right beam which seemed to tip it over.

I would like to read the AAIB report if there was one.