NTSB Final Report Transair 810 737 Ditching Honolulu July 2021
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- เผยแพร่เมื่อ 5 ต.ค. 2024
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1st video: • Transair 810 737-200 ...
ATC Audio: • (Fixed Audio) Ditching...
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A very old Chinese saying is: "He who has made a mistake and doesn't realise this, has made two mistakes".
Yes, exactly.
not very inclusive of all pronouns
like my 2 kids
Not so old that it hasn't lasted the test of time 👍
@@sleepyman-h1p Lol @ that 😁
I was privileged to survive two seperate engine outs while passenger on a 737-200 configured as cargo/passenger. Both were out of Anchorage International. Both happened on departure after V1. Both were on the same aircraft. Both were on the same day, several hours apart. That sagging feeling you get when departing, the aircraft over ice-flo infested water, is pretty vicerial. And memorable.
After the second attempt failed with the same engine failing, as we were departing the aircraft at the gate, the head flight attendant stated clearly and loudly what we were all thinking: "There is no way I am getting back on this damn airplane!"
We were transferred to a brand new 737-800, and by that time there was only a small handful of passengers left. It was an open-bar flight.
I don't know why I'm laughing, but I am. Glad you survived! BTW, *visceral.
@@lizj5740 lixdexia strikes again
Get everyone drunk and they'll feel better.
It would have to be. LOL
Good ol’ Pratt & Shitney
oh man, imagine going thru all that while you've got a perfectly functional engine notched at idle the entire time
I wonder what it did to their careers. I mean he did mention that teh company is no more.
@@Robert08010 who would want to employ them after that?
@@charlestoast4051 Maybe thi FO can reopen his lawyer-office. But the Captain with his age of 58 or now even 60 two years later and this story is probably a really beaten man today. All the best for both of them!
@@charlestoast4051 I suppose I didn't state the question clearly. I was wondering more if they let you continue to fly (assuming you are still able) pending the outcome of the investigation. I mean with an 18 month investigation, during that time, nobody knows the outcome or whos fault it was.
Like BMI 92 back in 1989.
The "did we screw up" part kind of stung a bit. I get why they couldn't tell him, but imagine thinking you were doing everything right in a hopeless situation and someone is like "uhhhh....did you check this obvious thing?" It's ironically less stressful if someone is like "yeah man, you really screwed up" instead of just wondering about it.
I imagine they did after the review was completed. The investigator can't ethically compromise the process. There have been several similar incidents with aircrews retarding the throttle on the good engine, and almost always with the same result - the loss of the aircraft.
It’s natural to think “did I screw something up” even if you know everything you did was right that question still pops into your mind. I’ve had an emergency and questioned it for months did I do something wrong.
@@davidmichael5573 yeah, that's kind of what I mean. The doubt is really stressful. Everyone has made a mistake before. It's way easier if it's like "you messed up"
"yeah, I did.... So what now?"
Then you take the consequences and move on.
I understand doing that would compromise investigating things.
Even if it's a minor mistake and you know the punishment is going to be basically nothing, and even if you are pretty sure you did your part correctly, the doubt and stress is really rough.
@@davidmichael5573 My first day as a captain at my first 121 ops, I had an engine fire. This was the 4th and final leg of the day. The first leg TSA had done a random audit and placed a fake hand grenade and fake knife in the the seat back pockets. We found it on the security sweep. Now my senses are heightened…..next leg I realize I have an illegal dispatch, weather was down to mins, but they didn’t add an alternate. Called DX and they fixed that. That turn down, was taxing out for T/O. It was a non standard day for this airport (the winds were not the normal direction and thus were departing the opposite runway) this required us to taxi to the far side. Normally it would have been a short taxi and then T/O. What happen next would have happened on T/O, probably after V1, but since we were taxiing to the far side…
We got an engine fire.
I still remember the the FO stating ‘MASTER WARNING’ and me almost nonchalantly saying ‘Cancel and Identify’ thinking he had said ‘MASTER CAUTION’
His response was ‘RIGHT ENGINE FIRE’
That snapped me back to reality.
I looked up and saw the RED T handle lite.
I stopped the taxi while calling Ground and stating we have an engine fire please roll the trucks and as soon as I had the aircraft stopped began going through the procedures. Completed I sent the FO to evacuate the PAX. I reviewed again the checks, concerned I did not do something but didn’t see anything. I left the flight deck, check the cabin and got out. The FO was with the PAX, all OK, and a fireman came up to me. He said didn’t look like any fire. I said OK, this plane is now yours and made a call to DX. I BRIEFLY stated what happened and would call back once the PAX were back in the Terminal. Next I called my Rep, who happened to be my best friend and whom I went to flight school with. I told him what happened and that I wasn’t sure if I did everything correctly. My nerves were pretty shot!
I was going over the events with him, questioning all my decisions, very concerned I had messed up. He interrupted me trying to go over everything by repeatedly stating my name until I shut up.
Then he asked ‘Is everyone OK?’
I said ‘Yes’
He said is the plane damaged or anything else?’
I said ‘No, except the engine fire.’
‘He said then you did everything correctly when it comes to the big picture.’
That REALLY helped me.
To this day I am actually grateful for that experience and my friends support.
I truly believe it has made me a better pilot.
Oh man - sounds like a truly shit day. Glad you had good support from your friend.
The lesson here is that it can happen to anyone. Confirmation bias is extremely potent.
My first thoughts were ‘what a couple of idiots’ but as I continued watching I began to think ‘that could have been me’.
It’s easy to sit back and say ‘they should have done this or that’ but at night, over the ocean you can understand their panic.
@@axelknutt5065 Since the second engine that they had assumed faulty was still at idle and not showing high EGT, it baffles me why neither pilot thought to spool it up to get enough thrust to get back to the airport.
After 25 minutes, I would have thought that they would have realised that they may have idled the wrong engine.
I think that to a lot of pilots EGT is just a figure that they do not fully understand, On heavy marine diesels, the highest EGT on any cylinder is what sets the full ahead speed governor. If the cylinder has a blocked injector causing weak mixture to run hot, it is often shut down in order to increase RPM. On very large engines, repairs to the injectors can be carried out while the engine is running, by also shutting off the inlet valve to the cylinder.
@@wilsjaneA bit off topic but I'm really intrigued about weak mixture causing high EGT on a diesel. Is this a peculiarity of big two-stroke marine diesels?
As I understand it the mixture is always "weak". (Except if enough fuel is injected at max power to produce a lot of soot in the exhaust).
You appear to know your stuff. Is there a quick explanation or can you point me to a resource?
@@alanm8932 The marine diesels, used on tankers, container ships, cruise liners and var ferries, run on heavy diesel, with a Redwood viscosity of around 3,000 seconds. This fuel needs to be stored at 50 degrees centigrade then further heated and filtered prior to injection. Almost all this heat is obtained from the engines, with a few isomantle heaters used on pipes and injectors, Being the residue of fractional oil distillation, it is cheaper but more importantly has around 20% higher calorific value per cubic metre.
Cold engines are started on standard 35 second fuel, then switched over when everything reaches the correct temperature. Needless to say, the fuel is switched back prior to shutting the engine down. Due to pollutant exhausts, many countries do not allow heavy fuel to be burnt in port or their national waters, unless exhaust scrubbers are fitted. These are mostly used on short hop car ferries.
These engines have a minimum design life of 30 years running 24/7, with a cylinder head valve replacement every 10 years.
By comparison, an F1 racing car has a valve design life of 8 hours on the track.
Back to the original point. To maintain the design life of the marine engine, EGT is absolutely critical to avoid rapid deterioration of the exhaust valve seats. Sensors on each port controlling the "full ahead" speed are the normal solution. Military vessels have a bypass system, for use when engaged in battle.
I am sorry that it took such a lengthy explanation to put the whole thing into context.
@@wilsjane I'm not a pilot, a mere terrestrial dick, but I wonder if they were nervous about increasing throttle on the engine they thought failed for fear of causing it to frag and puncture fuel tanks
A 50 year old engine with over 100k cycles!..... I can't think of a single thing that could go wrong lol
Don't these engines get completely rebuilt after a certain number of hours ?
Shocking!
@@coolasice2187 The two blades that failed don't appear to be rebuilt. They seem to be original, judging how aged they look from the photograph. LBJ was President when the right engine came off the assembly line!
@@zoso73 ok. But I'm still wondering...
@@coolasice2187 They get torn down inspected and parts changed, but AFAIK not the main fan or turbine assembly, that would all be original.
They do fly fine on one good engine, however it is vital to have it spooled up. 🙄👍
Yes.
If you've ever felt pure panic. then you know it causes you to lose your mind.
If there is confusion which engine is working simply advance both throttles to full power. Identify the good engine by performance. Then use the good engine. Go through the shutdown checklist for the disfunctional engine! Fly the airplane!!
Yes, indeed, and don´t waste your time with a chaotic attempt to explain to an overworked and distracted ATC thant you´re in trouble.
737 looks to be a better submersible than titan...
Lmao
It only broke and did not collapse, yes.
Yeesh 😂
Every so often we practice a flamout during descent in the sim. It's a tricky one as both engines are at idle with little asymmetric thrust. Yes that red-lining EGT was the best clue they had to identify the bad engine, I think their belief that both engines had failed also shows how little trust the crew had on their aircraft and quite possibly on their company's ability to conduct proper maintenance. As always thanks for an excellent review.
That is really good insight. It would absolutely have an instant impact on your responses no matter how much training.
They had 2 engines running although 1 was at idle because they thought it had failed, the other WAS failing. Before I would allow the plane to be lost, and be possibly be killed in the process, l definitely would have brought the other engine up to see if it possibly would last long enough to make it to the airport.
While listening to these kind of reports I just wonder where is the common sense ! ! !
@@brucejones2354common sense is inaccessible in high stress, hence the importance of training, not sense.
@@brucejones2354 On page 211 the interviewer asked him just that: ". . . was there any time in that time that you thought, you know what, let me just push the number 1 up just to see if there is anything." That's where he says no, I was busy w/ the stick shaker.
I'm not a pilot and don't know what you are trained to do and not do when the stick shaker goes off but in that situation, where you already know you are going down, I would think it would be instinct just to shove the thrust levers forward w/o looking at them or even thinking about it. What do you have to lose? Surely you aren't concerned about finishing off the engine you think is going bad.
Again, I'm not a pilot, but I did used to race cars, and I still do track days in fairly quick cars. If I had experienced poor braking during a race and decided that they were about gone, I would not, if someone spun directly in my path, have the mental thought process the pilot said he had: I know my brakes are gone and will not do any good so I am not even going to bother to hit them.
Right after that the pilot said something not mentioned in the report or in Juan's narrative, that he thought the No. 1 was already at full thrust. Does this plane's FDR not record lever position?
I'm guessing it's more subtle than you would think. Practicing engine outs in a piston twin, I expected the prop to stop dead in front of me, but it doesn't! It still spins and makes noise. You have to to through the "dead leg, dead engine" drill, and pull the power on what you hope to be the dead engine. And try to get it right, without running out of airspeed or altitude in the meantime.
I flew for Rhoades Aviation, I believe it was 1986. If you look closely at the name on the airplane in my icon. Had the same thing happened to me, without the crash. I forget who we were subcontracting for, but it was our first flight for them. From Syracuse to Philadelphia. Taking off out of Syracuse climbing through 3000 feet we suddenly had a red light for the low oil pressure . The captain reached over and grabbed the right throttle and retarded it back to idle and then move the mixture to idle cut off. After he did that I grab the quadrant and told him I'd verify and communicate, said he needed to fly. With a quick check I found he had shut down the wrong engine. I returned mixture to auto rich brought the throttle back up to its last setting. The prop hadn't been touched yet. I proceeded to shut down the left engine. The correct one. We flew back on one engine without a problem since we had plenty of altitude, it was a gradual descent all the way back to Syracuse. We had to start the left engine back up on landing, because of snow and ice and it was very difficult to taxi. the next morning the engine was frozen when we came out to check. Couldn't even move the propeller. had one of the mechanics with us that trip. He pulled the oil screen and it was full.
I did leave some stuff out.
Seems like they haven't changed much.
Sorry guys I was flying a DC-3 at the time. Rhoades Aviation only had DC-3's and Beech 18,s at that time.
And those planes are as basic and simple (read - safe), as they can get!
That's why so many cargo outfits ran them - and some still do.
737-200's are still great planes, but the problem these days seems to be, pilots are taught glass cockpits nowadays: throw analog instruments at them, and it's a whole different world. There are little tricks & quirks to flying older planes, that don't have computers to tell you everything you want to know.
Kinda like taking a new pilot that was taught in the latest aircraft, then putting them in a Curtiss Jenny: they'll figure out how to fly it, but may complain about trying to figure out what direction the wind is coming from on an app on their cell phone, all while bitching about that damn rag that the mechanic left on one of the wing struts!
Same thing in my present line of work- truck driving: new drivers don't learn with manual transmissions anymore, only automatics. Put these new drivers in snow with automatics, and watch the accident rate skyrocket.
Beech 18s! Good Gobble Goo! I flew scheduled for old Emery Air Freight. So you lived to tell the tale of flying 3s & 18s! Congratulations! You & I are probably the last two survivors. Everybody else is d e a d. Except for Britcarjunkie up there.
@@billcallahan9303 I've flown in all kinds of fun stuff, even Traumahawks, ScareCoupes.
@@billcallahan9303 I cheated! I didn't fly the 18's. There was no way, my dad had a bunch of time in them (he's 91 has a smidgen over 30,000 flying hours). So there is no way I was going to fly 18's. Used to fly with him when I was a kid. He would fly baby turkeys in DC-3's back East somewhere. I hadn't really thought about how many of us that were left.
@@Britcarjunkie Mr. Britcar, we have a 2,580 foot grass airstrip. Two idiots overshot the runway on landing! Yes, overshot it in a Scarecoupe! You really have to work at that to do it in a Scarecoupe! They ate several trees for dinner but lived to be embarrassed for life & still have splinters in their asses. Two more pea brained idiots, Undershot the runway (same one) had trees for supper that were over-cooked as a fire destroyed them, their Scarecoupe & the poor innocent trees they hit. Both true Scarecoupe stories. North Florida. 2JO.
"Aviation, in and of itself, is not inherently dangerous. But it is terribly unforgiving of any incapacity, neglect, or error.."
There was a lot of that on this flight.
This reminds me very much of the Kegworth accident here in the UK, similar model of 737 and they shut the wrong engine down. Crashed on approach to East Midlands trying to fly on the bad engine, hitting a freeway embankment. Many passengers killed and injured. Thank goodness this incident caused no loss of life.
Confirmation bias is so insidious. Been there and done that (as a student pilot). Thankfully, the tower guys straightened me out without a number to call.
Excellent work by the interviewing investigator in that transcript. Avoided giving an answer that could bias the interview without being dishonest and turned attention away from it, came back to it, didn't get confrontational, got the info and got out. Well done.
Indeed, exactly.
All that was impressive, but earlier he he led the interview in such a way and proposed answers that the captain knew what he was getting at. Much better to ask the questions almost as if they are a routine checklist to go through. I suppose somewhat like a psychological profile might be done ie. DSMV.
Man o Man, of all the times we practiced the engine out procedures ......when I had mine taking off out of SFO on AB321 in rotation it was like "back in the sim" ......... and then the dead engine re-lit at 600 ft (airbus does a self-analysis of the engine and will try 4 times to relight ..... but had severe vibration (normally 0.2, now at 10.4) so we left it at flight idle (in case we needed it). We came back for an overweight landing. We swallowed 40 seagulls during rotation bending 14 of the 36 blades on engine 2. TRAINING TRAINING TRAINING .... it pays off. Thanks for the report Juan ........
Ah yes. The ol’ “isolate the wrong engine” type of accident
it has happen quite few times, at what point does doing nothing and just letting what ever engine is failing burn it self up, become the better option?
Sound like zero common sense again. Even if they had idled down the failing engine, if you are going to go down into the water because of not enough thrust. What the hell have you got to lose bringing up the thrust on the bad engine? In this case it would have been the good engine and it would all have been good. No common sense.
It's just ALWAYS this problem. Or maybe it's because if it gets this bad, then we hear about it. But dang, shutting down the wrong engine. Oof
@@walkingman9171 some times the brain works in mysterious ways that later seems to make no sense. The objective must be to find procedures that avoid that
Are the gauges arranged sensibly? Engine one on the left two on the right? Or is this another case of confusing gauge layout? Did conditions (say, a violently shaking engine) make reading the gauges difficult?
Ya know..... This is the first jet I checked out in as an FO and also as a Captain. This whole scenario makes me shake my head. Now I'm not the sharpest knife in the drawer, but holy crap, these guys really effed up.
at least nobody died!
Amazing ditching skills, terrible CRM / ADM skills.
easy to say. until you are in a circumstance you've never experienced, panic is at your finger tips, and your brain convinces you that something is happening that really isn't, and you efff up, and go down the rabbit hole yourself.
Not being a pilot but with one engine glowing and not delivering enough power, I can't see why I would not try to coax some power from that other engine - the one *assumed* broken. Just 10% power from that one would have made a significant difference.
And as we know from the report - it would have surprised them by delivering way more than 10% thrust. They would suddenly have had all the power needed to safely land.
History already have lots of planes surviving with engines not delivering full power. So why not check and dual-check and tripple-check the thrust lever position of the non-glowing engine???
@@octagonPerfectionistOnly because it was a cargo plane, with just 2 crew onboard. Were it a pax flight the outcome would've been much worse.
Ditching at almost 2 in the morning? Granted, they put themselves in the position to have to ditch but that's still a mighty impressive thing to swim away from.
I’ve flown many ROUND gauge airplanes in my day, only had one engine shut down in flight, Lear35 with Garrett 731’s, but going through the quick look see, red fire warning light, bell, go down the column of gauges and see the egt going up, the epr gong down, just to be 100% sure which one was bad. Hit the fire bottle. Shut down checklist completed, decided to land at nearest airport.
Change underwear.
But this was done in the daytime, crew had plenty of rest, also crew worked well together. I flew, he did everything else. Landed safely with zero issues.
To be under extreme stress and a not so well maintained aircraft, guess it was a totally different game.
At least they lived to tell there story.
Indeed. Thank you for sharing your experience. And you´ve probably not confused communicate with aviate and distracting yourself by a chaotic radio communication with an overworked and itself distracted ATC.
@@NicolaW72 I thought she did a pretty good job.
EPR gauge on a Lear 35? That's different.
I was on Maui about a month before this accident, on a beach near OGG watching planes while the kids were playing in the surf. Saw a plane takeoff that had much darker engine exhaust than all the others so I looked it up on Flightradar24. I remember noting to myself that was probably the oldest 737 I had ever seen. It was crazy that it was the same airplane involved in this accident the next month.
I remember reading about a DC3 running cargos between the Hawaiian Islands. About 10 years ago.
Very interesting human factors case. IMHO it shows that if you start off disorganised, confused or distracted, a crew rarely recovers from it. The FCO accident and Turkish in AMS were similar. The fact that the F/O was PF AND doing the radio at take off was the first sign that the captain was out of the loop for one reason or another. Not adhering to checklists, unable to decide which one to use, then grabbing control when things were getting dicy was a sign of disorganisation or panic; that’s when the reverted to seat of the pants only.
Man! That F/O was lucky that he wasn’t knocked unconscious or got trapped when the seat broke on impact! Glad they both made it out safely! Quite an ordeal! Great review Juan!
A very good point, indeed. "Admiral Cloudberg" made shortly a very good blog about this accident, too, with very interesting additional informations - really worthy to read.
Reminds me of the distraction over a gear indicator on Eastern Flight 401. I'm glad both survived.
Sometimes it is the little things that can get overlooked that can save yourself and the plane. Checklists are there so you don’t forget that little thing. Glad the crew made it out and survived.
Human memory is fallible. I had IT jobs with so many details checklists were natural but not always used. My wife handles her medicine supply in her head and it just doesn't work. But a checklist is a "crutch". Pride is why checklists are as rare as they are.
Many years ago in the service, somebody gifted our C.O a carved plaque bearing the old line from Ben Franklin: "Beer is proof that God loves his children and wants them to be happy". This was a gag gift, as he was a bookish sort and a teetotaler (but a good sport).
A couple of weeks later, we see the plaque on display: he'd taken a chisel and a paintbrush to it, and it now read "Checklists are proof that the Air Force loves her children and wants them to be alive." The point was taken!
@@jasoncarswell7458 Imaginative. The Franklin joke is a favorite. And, yes, a good checklist can INSURE vital items are remembered.
28:50 I felt a sinking feeling in my stomach hearing what appears to be the captain suddenly realizing that he may have been a major factor. Glad they both survived.
Yes, I, too - with this questions around Engine Number 1 he probably started to realise that they "screwed up" - but astonishingly only then, eight month after the Crash with much time to think through what has happened.
The CFI that gave me training for my CFI ticket taught me that , if you take over the controls of an airplane during flight, ALWAYS physically touch all the controls, ie- yoke, throttle, trims, flaps, etc. , and assure they are in the correct positions before resuming the flight as necessary. Never assume the pilot that was flying......was doing it right. Had the captain practiced this when he took control, this may not have happened.
“ …having your head in the game 100% for every single takeoff.” I’m a paraglider pilot and so I try to keep this in mind every single time. You never know what can go wrong.
👍
The interview with the coast guard helicopter kids was great on this one.
Do have the link? I’ll add it to the description.
@@blancolirio Search - KHON2 speaks with USCG crew who performed rescue
Man did I feel that "Did we screw up?" -- That's so helpful. Like you know this guy didn't want to crash into the water, his instincts took over and not his training -- or their airline didn't value training the way that they needed to prevent this accident.
Glad no one got killed that night and we all got a great lesson.
Thanks for including that very humanizing element of the transcript.
Indeed.
The investigators turned every stone to be sure they came to the correct conclusion. Kudos to them. This accident clearly shows that we humans have limitations when it comes to cope with high stress situations, regardless of flight experience. This captain had experienced engine failures before, and still this happened. I really feel with the crew and hope I will never been put in a similar situation. Not discussed in this video is the fatigue element. Working when the body is programmed to sleep has a detrimental effect on human performance.
Hi Magnar! Will you do a commentary with your take/lessons from this accident? Your perspective is always interesting. :)
@@foowashere Indeed.
This Final Report must really be horrible for them to read. But I found it really astonishing that the Captain was even eight month after the accident absolutely convinced about the actions he took and obviously got only doubts when the investigators started to focus their questions onto Engine Number One.
It doesn't show "we humans have limitations to cope" .. It shows these Pilots screwed up. Stop giving the Pilots outs on resposibility. When you practice activitities.. you become skilled at those activities. I bet you can tie your shoe in the dark... because you've done it 1 million times. You practice response to the most dangerous posibilities.. over and over.. that's what makes you calm and familiar with the steps and able to do it easily when the real thing happens. A Pro is practiced up.
Well this one is going to be used as a Human Factors case study for years. Glad they lived to teach all of us the benefits of good crew coordination and communication.
Indeed. It has clarly this potential.
Great review! As a former USAF aircraft accident investigator, with a military/GA/airline flying/instructing career that began 40 years ago, I am always amazed when “Fly the Damn Airplane” is still a failure point and found causal. And yes, I’ve been there, done that. I lost a dozen T-38 engines over the years and two in the 727 - different days, and one was a real no kidding uncontained fire. I cannot even imagine NOT reaching back for that “spinning spare!!” What the heck are you saving it for? It was not even shut down!! That scenario is exactly why it (believing it had a problem) was not shutdown - or would not have been had they run the checklist. Sinking into the dirt/water… Balls to the wall as they say. Oh well. Glad they survived the severe breakdown. Not the engine breakdown - that’s why there are two engines. But the horrible breakdown of CRM, communication breakdown between the pilots, failure of the captain to follow established procedures and time-tested techniques, and the failure to use common cockpit sense.
Damn glad there were no passengers or cabin crew aboard…
You nailed it . I was thinking the same thing, SilogramVids
These pilots are the one's who asked Honolulu tower for "a vector away from the airport so we can run our checklist" ... then didn't run them. They flew away from the airport and out to sea when they were clear to land ..with a return over open water no houses or buildings to people to jeopardize. Their planed flight was less than 60 minutes to another Hawaian island.. couldn't have been over on fuel much if at all.
@@TenGreenRangers Yes, exactly. Thank you very much for this reminder!
You nailed it, indeed. It remembered me in the first moment to the Kegworth Disaster in the UK back in 1989 - but after a closer look it was much worse. They were really damn glad that they were flying a Cargo Aircraft without Passengers and Cabin Crew. But the whole situation at this Airline was messy at that time and it can be questioned how the relationship between this Breakdown and the broader situation in their Company was.
When i flew the Dash 8 once the engine was secured we would operate both throttles together to avoid this same situation
A possible outcome would have been for them to have shut down the #1 (good) engine. The put the throttles at half. Problem not solved unfortunatley.
Classic example of "there's a reason why we do things the way we do"
Reminds me of the C-5 accident from years back. They had an engine failure, but idled a good engine, leaving two engines to keep a fully loaded airplane in the air.
Juan, if you ever get tired of TH-cam, you’d make a great aviation book narrator! You had me on the edge of my seat reading the events from the CVR.
Drama! It reminded me of a Brian Lecomber novel, where the hero is nursing a Beech 18S into an island airport with one blown up engine, the other running out of oil.
I can't help feeling bad for them. Dark, 50 year old instruments/aircraft w/a lot of use. Not excuses just a bad situation. Thank God they survived it.
I did quite a few hours on that fin in the 90’s when it was at Canadian Airlines International. Sad to see it at the bottom of the ocean. Geoff Quickfall BSc, MSc, PhD candidate with 28,000hrs; DC10, B737, B757, B767, B777, B787, DHC2, DHC3, B18
Sad end of an ancient Aircraft, indeed.
This is a beautiful example of "Murphy's Law" and you can bet Mr. Murphy is just waiting for the next unsuspecting crew. High work loads and night flights, even in paradise will throw in a curve ball now and then.
Thanks again Mr Brown, play safe.
Good Lord, that old
pack mule had some hours on those engines.
Just glad they both survived.
Years ago, when I was in flight school, a Seminole was being flown by 2 instructors, one learning to be a multi-engine instructor from the other. The one instructing shut off the fuel selector for Number 1, when it quit running the one flying feathered Number 2. In the ensuing helmet fires the fuel was turned back on to number 1, with all the levers full forward, it lit off and severely over-speeded, damaging the prop governor which locked at the fine limit, so it could only make a little power. Emergency declared they went to work an trying to restart number 2, which takes awhile, without unfeathering accumulators. Meanwhile I and everyone else was sent out of the pattern by the tower to clear the way. I think they did get number 2 restarted. They flew it over to the airport and set it down with the gear still in the wells and slid to a stop in the intersection of the only 2 paved runways on the field, closing both runways. No body was hurt and the airplane flew again. Months later, I took my Commercial, Multi-Engine check-ride in it the day it came back on the flightline. Back to the big day, because I had experience landing on dirt in the wild west, I asked tower if the grass runway parallel to one of the closed runways (usually only used for taildraggers and gliders) was available, or if the whole field was closed. They decided the grass could be used for landings only, so a whole bunch of people got to land Cherokees, Mooneys and Seminoles on the grass that day, but the school didn't have to recover all its planes from all the nearby airports.
Young me took the lesson to identify, verify, think about it and then slowly move the lever to feather to heart. Older me (now) thinks piston twins sometimes, not often, can try to kill you very quickly during takeoff, and my superior airmanship may be insufficient due to slowing reflexes...so I choose not to operate them anymore. They at least twice as likely to have an engine failure (maybe more, since attitudes about having a spare can influence what condition seems tolerable) and just as likely to be fatal after an engine failure as a single. In a single the next steps are clear when the fan quits - put the nose down and choose where the landing/crash is going to be.
Agreed. Losing the critical engine right after rotating on some aircraft will lawn dart the craft into the nearest hangar if the PF doesn't quickly feather the bad engine. It should be simple: If your right foot is all the way at the stop, feather the left, and vice versa. But reality is that when shit goes bad, it takes a while to process it. Taking it slow might kill you in the rare engine failure after rotation, but it'll save you in 99% of all other engine failures. I'd go with your slow but measured type of aviating. Especially as you get older.
Part of my briefing as a wide-body pic was "no fast hands"
Nicely stated and very thoughtful. On many light twins after engine failure and the ensuing helmet fire, the second engine only functions to take the crew to the accident sight.
I got noggin fire reading this, in the comfort of my twin mattress.
@@tenpiloto What's the saying? Slow is fast, fast is good.
Wasn't one of the significant questions of Capt. Sully when Flight 1549 landed on the Hudson river was if there was any thrust coming from one of the engines (left engine?) that was running, but with a sub-idle RPM, and later confirmed to have no thrust whatsoever? FO Skiles still continued the restart attempts on both engines, until shortly before ditching in Hudson.
Glad that people are understanding it’s not about blaming the pilots, but understanding the human psychological factors that made them fail.
Indeed.
Shades of the British Midland accident at Kegwoth, where the wrong engine was shut down.
Yes, indeed.
That's exactly what I was about to say. I was just looking for someone else commenting on it first.
A similar situation happened with British Midlands years ago.
Aircraft failed to reach the runway and crashed on the M1 embankment
@@trafficsnitch3505was it at Kegworth?
@@trafficsnitch3505 Known as the Kegworth Disaster. Crashed short of the M1 actually, then slid over and onto the M1 and hit the west embankment. They only needed to make a it about another 200 yards to miss the M1. I was in Bedford at the time and drove up there on my way to Newcastle on the following Friday, I worked near J13 on the M1. By then the only sign of the disaster was some new landscaping on the other side of the M1. Every scrap of clear evidence was gone.
And the pilots only had to ask the cabin crew to look out of the windows to see if there was any signs of an engine in distress. Even better, one of them could have walked back into the cabin to look for himself. But that was too simple!
And the short section of new metal barrier in middle of the motorway.
Well, any landing you can swim away from ...
...is not a good landing.
Yup, seen this one before. British Midland Airways brand new 737. Just 12 weeks old. Thnx Juan. 😊
Thank you for the follow-up on this one. It's been a bit of a head scratcher, and honestly still is. I had believed they would have had both engines limping along with whatever they could have gotten out of them. Crazy to think all they had to do was push the throttle forward on the good engine. Tunnel vision is a very serious thing. Several very good lessons here, thank you.
Despite his clouded tunnel vision, I still have empathy for the 55 year old captain, as he has clearly "lost a step or two" in his thought processing. It happens to all of us at different ages in our lives. He is lucky to be alive. Thank you for this program, and I don't understand why, but there were no ads in the ad tracker for this one.
Glad no loss of life. This is a learning experience for the industry.
Indeed.
Indeed, but the "what can we learn going forward" part is the kicker, given this is not the only time something like this has happened.
Maybe not. Industry hasn't learned from all the other times.
It's amazing how often this has occurred. Whatever caused neither pilot to think of attempting to operate the remaining engine is worth a close look as well.
Yes, indeed.
As a pilot about to do my multi training, I will now start calling out the failed engine when my instructor simulates a engine failure so that both crew let that info sink into their heads.
With engine failure in a multiple engine aircraft, the first thing we would do is verify which engine has a problem, and that is performed by gauge check and slowly jocking the throttles to definitely verify who is working and who is not. This is on pre millennial aircraft that does not have a computer to tell the pilots everything that going on. Making sure the engine is broke also prevents CNDs.
Thank you for this breakdown and explaination -- very useful info & instruction.
Confirmation bias & tunnel vision go hand-in-hand, which is one reason checklists exist. However, separation of roles broke down at the behest of the captain, and objectivity was lost. The only way to mitigate is through proper training, which *must* include "startle training". Without startle training, it can be difficult to recognize your own compromised mental state/thinking, which can lead to incorrect problem identification & appropriate response(s).
One critical thing that must be done is to maintain current separate roles, because switching roles introduces significant increased workload and confusion, which greatly diminishes ability to identify and take proper corrective action. The only exception to this is if one of the pilots are/become incapacitated.
In my training I was taught to "take a beat" when something unexpected happens -- meaning, don't react right away, take a breath, then assess and respond. As with all generalizations, there are exceptions.
There were lessons learned from this incident, and training overall has been made better from this.
I'm glad both pilots were ok, and I hope they continued to fly after this.
👍 - This Final Report must be dreadful for them to read.
You are so right, as always. Misidentifying the bad engine has occurred several times before, sometimes with the pilots recognizing their mistake in time while at other times failing to realize their mistake and resulting in disaster.
Well, the F/Omade a huge mistake, but he's probably the one who saved them from entering a stall when he "convinced" the captain to set the flaps to flaps 1. And kudos to the F/O for directing the coast guard to rescue the Captain 1st. Given the fact he was injured himself, and without a doubt traumatized being in the dark ocean, it goes to show his character.
Great analysis Juan. It reminds me of the 73 crash in the UK (British Midlands?) where they shut down the operating engine and crashed on a highway short of the airport.
There have been other incidents like that where the pilots shut down the wrong engine. TH-cam has videos of some of them.
From memory I think the engine instrumentation had been wired wrong for left and right ?
@@ridbanner1407 I don't think so. That would be evident upon engine start.
I think you are correct , it featured as a possible theory at the time. turned out cabin air on old model came from left engine ,new model right engine which pilots did not know ,so smell of smoke triggered wrong side shut down.@@gerardmoran9560
"Shutting down the good engine" has to be one of the oldest causes of crashes in aviation
Yes, indeed - next to CFITs
"5 Engine failures". That's horrendous. In my 27,000 hour career I only shut one engine down and that was a precautionary shutdown for high oil temp. It was a failed thermocouple.
It tells indeed a lot about the situation in this company at that time.
Regarding the First Officer reading back the takeoff clearance, it does make sense. The Captain would have been taxiing the aircraft when the clearance was received (VERY few 737s are delivered with a steering tiller on the right side), so the First Officer would have been handling the radio. About the only time you'll hear a 737 Captain read back a takeoff clearance is when the aircraft has been given a "line up and wait" clearance and is holding on the runway, waiting for a takeoff clearance. Then the Captain may have already transferred controls to the First Officer.
[Fun fact] I am a Commercial aviator with 13,491 total flight hours in the business class industry of aviation mostly. I was sitting here thinking “they shut the wrong engine down? 🤔 how could they have done that? There is no way that would ever happen to me!” Then this whole time I would have sworn I was subscribing to your channel, because I watch every video when they come out. But I went to like your video, and noticed that I was not subscriber. So now I’m rethinking “would I really shut the wrong engine down?” Fact is, we don’t know how we are going to preform when we are put in their situation, until we are faced with it! You get a lot of uneventful hours over a period of 20-40 years, then you get comfortable with it over that X amount of time, and even though you train for it many times, then all hell brakes out, then your entire life, and the lives of all the other souls on board depends on what decisions you make within the next 5min to an hour, then you are going to preform much differently then when you did it in the simulator, because you can’t afford to mess up, when it is real LIFE that depends on you, and what decisions you make from that moment, to the threshold of that runway!
Indeed, exactly - that´s the point: It IS a difference if you´re sitting in a simulator, from which you can walk out every time and where you´re prepared to be checked, or if you´re sitting in a real Cockpit in a real Aircraft in a dark Night over an Ocean - and in a few seconds the Situation changed from anpther night at work to "Get it done NOW or dy".
I’ve flown enough airplanes at 0200 to know fatigue will prevent you from seeing/processing the big picture, I’m also experienced enough to understand there’s no mistake any of us couldn’t make….I put huge effort into making sure I’m seeing what’s really happening. 36 years in and it’s still the most challenging aspect of my job.
👍
True true and true. Our brains are both our best friend and deadliest enemy but with an attitude like you’ve just stated I’m betting you’re going to be good in the long run. 👍
One can’t help but think the many engine failures at their outfit made it easier to believe a dual engine failure happened
Wow! Great review. This sounds so similar to the C5 accident at Dover AFB in Delaware back in 2006.
Maybe checklists should have a line item near the top of the checklist that says "if all else fails push both thrust levers to max. or 3/4 thrust" or something like that as an item that could save the flight, or bring the crew out of tunnel vision. Would there be any downside to do that?
it could conceivably cause an overheating engine to catch fire. But I agree with you, push em to the stops and figure it out after you get speed back.
A checklist by nature can only assume all prior steps were completed correctly, otherwise it becomes something other than a checklist.
Great analysis, Juan. Target fixation/tunnel vision has nearly killed me a couple of times on two wheels. As you probably know, the motorcycle goes where the rider looks... Focus on the obstacle, and damned if you won't hit it every time.
IMO, the Capt'n failed the most basic engine out procedures. Throttles forward, identify dead engine, re-set for single engine cruise and maintain altitude. 😞
Thank you Juan for reading out this report, it reminds me of the accident here in the UK when the pilots shut down the wrong engine only over here one of the investigators said shortly after the crash that the wrong engine was shut down, unfortunately lives were lost on this occasion, just shows that pilots are not learning from previous accidents, I think it was a new aircraft in the UK accident showing that the age of the engine doesn’t mean failures can’t happen
Great video as always. So glad you did not denigrate the aircrew. Very easy to do when you are not in that situation.
Yes, indeed.
Juan, Thank you so much for doing this update. I remember when you covered the accident right after it happened. Also, thanks for taking the time to explain the graph from the FDR. I’ve always wondered what information was captured and how that information was displayed. When I first saw the graph, I couldn't make heads or tails out of anything, but your explanation was top notch!!
I've been watching you and Mentor for many years. Both of you are a blessing to the TH-cam community!!
Great video, thanks! I felt sorry for the captain by the end of the interview, when the truth was starting to get through. So glad they both survived!
Yes, I, too. Probably he´s today a beaten man.
Great analysis and transcript. They survived, no one externally got injured. Lots to learn though even with the crew’s experience the situation overwhelmed them. Just goes to show no amount of simulator time or real life experience can guarantee the right outcome in these situations. At least their back with their families after all this.
Indeed.
I looked up Rhoades Aviation out of Hawaii, it’s the same company I worked for in the late 80’s in my hometown of Columbus Indiana before going to college. They flew cargo out of the municipal airport using DC3s, Beech 18s, and had a Super Constellation before it crashed in the early 80’s on takeoff, killed the crew. They also had a KingAir C90 and a Citation. Not sure when they closed up shop in Columbus, they had a lot of problems.
Avigate (make major simple error)-Navigate ("get us the hell back to the airport")-Communicate...("WTF"?) and star in one of Juan's TH-cam videos!
Glad they survived...I hope the NTSB looked in to the reality that they're very much on the back side of the clock, flying at "o'dark hundred" with proably not a lot of quality rest prior to flight.
Holy carp, when in doubt push both engines to the stops, in other words floor it and go from there. The egt gauges will identify whats sick and whats not.
and if avoids a crash who cares about an engine that is already damaged
@@fuzzy1dk yep
I'm so glad they survived to talk about it. Thanks for the update Juan, and greetings from MBJ airport Jamaica.
Key words here: Tunnel Vision. Thx Juan.
I recall a comment made regarding aircraft in general: "Every aircraft that has ever flown (ascended) has always landed (descended)".
This job included a multiple repitition schedule. Adjusting the brain from out of the ordinary after an upset at night when the brain says it should be asleep is tricky. I have not flown but have operated machines at night and there is a challenge to the effort as anyone that has done it would tell you. I applaud those who thrive in this time environment. As computers take over more of the attention of the operator there is less for the brain to handle and nature is what it is.
I was once working on a an industrial gas turbine driving an oil pump package at a remote site.I was sent there after the junior tech had trouble with the control system and could not get it to speed control properly. This junior tech had been there for three weeks doing the start up on this unit and the customer was concerned that this guy could not fix the problem. When I arrived the unit was running and it was not rapidly responding to speed changes from the electronic control signals from the station. Since this unit had a control computer that sent a 0 to 10 VDC signal to a hydraulic actuator with a linkage to a natural gas fuel control. A spring was installed on this linkage that would move the throttle to idle when this hydraulic actuator would retract to the idle position. The tech was bent over his lap top trying to "Tune" the response and was running a diagnostic graft that showed all the parameters much like a flight recorder. After watching the grafts output for about three minutes I walked over to the unit and opened the enclosure door and watched the throttle in real time with my A One Eye Balls. The Hydraulic actuator has a roller on the end of it that rolls against the fuel linkage arm and during speed changes the spring is supposed to keep this roller in contact with the linkage arm. The linkage was sticking some how and the hydraulic roller was retracting to minimum so there was a definite gap between the two. After about 30 seconds the vibrations from the machine would over come the sticking point and the spring would snap the throttle to idle in a big step change. The tech was so focused on the electronic tuning and his lap top that he never thought to actually get up and watch the throttle in real time. The problem turned out to be the support frame that held this system was 1/4" too wide and had been made wrong at the factory. I verified this because there was another identical unit in the building next door. All we had to do was remove one roll pin from the end of the "axle" of that shaft while leaving the other end pinned in its ball bearing and that fixed the problem. Tunnel vision can cause you to focus on ONE problem and totally miss the Real problem.
Great summary of the NTSB report appreciate your depth of knowledge and experience as a pilot. With all due respect to the caption and his flight hours. Amazing how a stressful cockpit incident once again resulted in tunnel vision. Very interesting how after all that time post accident the captain didn't recognize the error. But certainly wanted to know if the flight crew were responsible. I am grateful there was no loss of life.
For the truly proficient, a second engine can be a godsend. For everyone else, it is a distraction which assists the pilot in reaching the scene of the accident.
I'm still confused how they forgot which engine was failing. Its a fascinating look at human psychology and the effects of stress. As Juan pointed out, the pilot interaction was scattered, highlighting the importance of good flight-deck management. Its a little strange to me, given both pilots were fairly senior and experienced.
Indeed.
Pilots get paired differently every flight, so you won't have as good coordination under stress as if they had been flying together all the time.
@@djinn666 Don't the majors send their pilots to cockpit management classes? I assume this takes into account mixed crews and establishes generic protocol for emergency procedures.
@@djinn666 As Juan pointed out in the Video: They had only 24 Pilots in this Airline. It was a really small Business - and probably all Pilots of this Company new each other very well and had flown together often. That Airline was not American Airlines or Delta with their thousands and thousands of Pilots.
Story a bit reminiscent of the TransAsia Airways Flight 235 out of Taiwan. Thank for the detailed rundown Juan!
The captain said he had experienced 5 engine failures and 7 precautionary landings with the company and had even been "reprimanded" for not completing checklists. You would think with that level of practise and the feedback he could have handled the situation a bit better.
There was a similar tragic mistake on an early 737 in 1989 when it crashed on a diversionary approach to East Midlands Airport in the UK, It came down near the village of Kegworth, smashing into the M1 motorway (highway) about half a mile from the runway. 47 people died in the crash and 70 odd were injured. By some miracle none of the vehicle traffic on the highway was affected. The investigation showed that the crew misidentified which engine had failed and shut down the good engine - very similar to this Hawaiian situation. I believe the main problem was difficulty in reading the vibration sensor indications on that early 737.
It's possible that in their pilot training, they always only ever trained for the #2 engine failure. So when #1 failed they went to their training and acted as if #2 failed, just like in their training. I've heard of that happening before. The FAA calls it "Norms" as part of the dirty dozen of human factors
Wait... really?? Who TF doesn't alternate between engines when training for engine failures?
These guys were in their 50s with tens of thousands of hours of flight time and you think it’s plausible that they only EVER experienced an E2 failure? Also, E2 IS the bad engine in this story. E1 was good the whole time. Baffling logic.
Yes, #1 is the one everyone trains for because it is typically more deadly. That’s why dead foot, dead engine comes before identify, verify, feather.
The captain knew they effed up during the second questioning.
I hope he’s ok.
@@georgewchildsI didn’t realize jets had a critical engine, or that you had to feather a turbojet engine.
@@nocalsteve Now you know.
Great update….weird issue to complicate a flight but at the same time just fly the plane first then sort out the problem calmly and efficiently……
After reducing number one to idle, the F/O forgot which engine was the good one when he needed to add power again. With both engines at idle and no other obvious indication as to which one is bad…no fire warning, loss of oil pressure,etc (and no dead foot) and not yet having secured the bad engine he just grabbed the wrong thrust lever.
Indeed. And the Captain was distracted by the radio communication chaos.
They both had a terrible case of CRS(can't remember shit) or CRAFT(can't remember a fucking thing) as they both knew which engine was bad
Great reporting as always! You gotta feel for these guys, handling crappy old equipment and then getting themselves into a losing situation and mentally not being able to get out.
Yes, indeed.
Thanks Juan.
This is infuriating. How damn can they be comfortable with guessing which engine failed and never going back to it again ?!? I mean when things get real bad, wouldn’t you want to check again on the engine you shut down in the first place to see if it can provide any thrust, regardless of whether you believe it failed or not ?!? That’s insane.
I thought it would be cool to get a pilots license. After watching your videos, I realize I don’t think I have what it takes to be a safe and effective pilot. I love your reviews, they are so interesting. You sir, are a true expert in your field. It’s nice to know people like you are educating people and taking things so seriously.
A great analysis as usual! And speaking of having one's "head in the game", there's a great analysis from Admiral Cloudberg on Medium about how the captain was strenuously denigrating a female FO to the accident flight's FO for an incident the day before in which the female FO refused to fly with the captain. He apparently was complaining to the accident flight's FO up until the plane took the active at HNL. A complete lack of a sterile cockpit. If true, this captain should not have been flying that night at all.
Maybe one day the NTSB will consider emotional and psychological disposition and well-being as a contributing factor to their accident reports. Context matters.
Yep!
Thank you very much for this interesting additional information and tip!
link?
@@KuostA You type in "Admiral Cloudberg Transair Flight 810" into your search machine.
Love how the report said what I've been thinking since I heard it live.
They tried to use the dead/dying engine in the end.
Yes, there were many assumptions in this direction from the beginning - and they were right.
As a former T-38 FAIP I have seen students shut down or misidentify the bad and good engines many times in the sim. Less likely for someone with experience but this is why CRM is so important. 1) maintain aircraft control 2) analyze situation and take appropriate action. Looks like step 2 was missed.
I thought this over: I respect these pilots. Why? When I flight-sim, I learn things, and, I learn as much about myself as the aircraft. It's so EASY to forget! I mean, EASY! I have about 11 years on these guys, I can EASILY see how, in the "heat-of-the-moment" you could just "lock-in" and totally forget that No. 1!
These are the Pilots who asked Honolulu Tower for a vector out to sea.. "so we can run checklist" .. and then didn't run them. They were cleared to return and land with an approach over open water.. no buildings or people to jeopardize. Their flight was a planned 50 minute hop so their fuel weight couldn't have been terrible. These are also the pilots who were too sheepish in their communications to clearly communicate their emergency to Honolulu Tower. Amazing how when you practice responses to scenarios .. when the scenario happens you are able to function. You want me to believe these guys had drilled engine/out or 2 engines out once a month out of profesionalism? You don't have to be in a simulator to do so. Maximum vulnerability is a takeoff .. that's where every pilot's training should be razor sharp.
A reminder of the human factors involved and possible outcome regardless of how good we think we are. Two lucky pilots with a story for all to hear and learn from. Thank you for your well presented in-depth follow up /break down Juan.
When I was working in Hawaii I remember seeing a trans air 737 they had wooden pallets holding up the tail section
Tbh, "wrong side" is a problem absolutely everywhere where it can happen. Think for instance, knee or hip replacement surgery. Nothing looks the same as the side you're working on as much as the other side you don't want to be touching, and no amount of creativity will prevent people from getting the side wrong sometimes. Best we can do is put checks and marks and rechecks. In this case, a big red sticker on top of the bad engine's EPR counter comes to mind as an additional marker - assuming it's feasible to stick it out without too much trouble / wasted time.
High stress in a life and death situation can challenge anyone.