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Tatarstan 737 crew possibly overwhelmed by spatial disorientation

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posted on Jan, 4 2016 @ 05:10 PM
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The crash report on the Tartarstan 737 crash has 17 November 2013 has been released. Many factors, including spatial disorientation were cited as factors in the accident. Among the other factors were an improperly aligned navigation system that led to the aircraft being out of position as they started their landing attempt, crew overwork, and poor training.

It's believed that the captain assumed that the aircraft was performing an automatic go around, and didn't realize that the autopilot was disconnected. The first officer was preoccupied with other duties during the first part of the go around. For 25 seconds the captain made no control inputs, then as the nose raised to 25 degrees, he pushed forward on the control column, and continued to push forward, until they reached a 20 degree nose down attitude.

The UK AAIB believes that under somatogravic illusion conditions, the crew may have believed that they went inverted as they went from a climb to a dive suddenly. The crew could have recovered as late as 5 seconds before impact, as they passed through 1,900 feet, and 40 degrees nose low. Under simulations, the aircraft could have pulled out with 200-300 feet left, and pulling 3.5Gs.

The crew received sink rate, and ground proximity warnings, but instead of pulling back on the control column, they pushed forward with up to 22kg of force on the column, until impact, at which point they were 75 degrees nose down.

www.flightglobal.com...
edit on 1/4/2016 by Zaphod58 because: (no reason given)

edit on 1/4/2016 by Zaphod58 because: (no reason given)




posted on Jan, 4 2016 @ 05:13 PM
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It sounds like spatial disorientation definitely played a role.

75 degree nose down into the ground


I can't seem to see any info on the weather for that day. Was there heavy ground fog or a low ceiling?
edit on 4-1-2016 by charolais because: (no reason given)



posted on Jan, 4 2016 @ 05:25 PM
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One thing I am a little confused about is whether or not they were actually doing a go-around. The article states at the very beginning that they did not know the autopilot was OFF. Did they actually begin to execute a go-around and start climbing or was this basically a descent right into the ground? Or did they flare up momentarily at the beginning of the go-around and then pushed the nose down.



posted on Jan, 4 2016 @ 05:25 PM
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a reply to: charolais

The fact that they went missed and had special d issues implies that the weather was probably pretty bad and below minimums.

How and why do accidents like this continue to happen? This is basic instrument stuff. Fly the airplane and sort out everything else later. I just don't get it.



posted on Jan, 4 2016 @ 05:27 PM
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originally posted by: justwanttofly
a reply to: charolais

The fact that they went missed and had special d issues implies that the weather was probably pretty bad and below minimums.

How and why do accidents like this continue to happen? This is basic instrument stuff. Fly the airplane and sort out everything else later. I just don't get it.



Exactly! I can still hear my instructors voice in my head whenever things got a little hectic... "Aviate - Navigate - Communicate - fly the plane fly the plane fly the plane!".
edit on 4-1-2016 by charolais because: (no reason given)



posted on Jan, 4 2016 @ 05:31 PM
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a reply to: charolais

Because of the engine placement on the 737, if you add power, and the autopilot is disengaged, the aircraft will go nose up. That's what happened here, causing the crew to think that the autopilot was still engaged, and the aircraft was executing a go around.



posted on Jan, 4 2016 @ 05:32 PM
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METAR for the accident date:


METAR Weather report:
14:30 UTC / local time:
UWKD 171430Z 23009G12MPS 9999 OVC009 03/02 Q0995 R29/2/0055 NOSIG RMK QFE735/0980
15:00 UTC / local time:
UWKD 171500Z 23009G12MPS 9999 -RASN OVC008 03/02 Q0994 R29/2/0055 NOSIG RMK QFE735/0980
Wind 230 degrees at 9m/s, gusting to 12 m/s; light rain, light snow; Overcast at 800 feet; Temperature: 3°C, Dewpoint: 2°C; Pressure: 994 mb

15:30 UTC / local time:
UWKD 171530Z 23008G11MPS 5000 -RASN OVC007 03/03 Q0993 R29/2/0055 NOSIG RMK QFE734/0979
Wind 230 degrees at 8 m/s, gusting to 11 m/s; visibility 5000 m; light rain, light snow; Overcast at 700 feet; Temperature: 3°C, Dewpoint: 3°C; Pressure: 993 mb

aviation-safety.net...



posted on Jan, 4 2016 @ 05:33 PM
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originally posted by: Zaphod58
a reply to: charolais

Because of the engine placement on the 737, if you add power, and the autopilot is disengaged, the aircraft will go nose up. That's what happened here, causing the crew to think that the autopilot was still engaged, and the aircraft was executing a go around.


That makes more sense. Thanks



posted on Jan, 4 2016 @ 05:44 PM
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The crew received sink rate, and ground proximity warnings


Isn't it very rare for the warnings to be incorrect? At least isn't ground proximity warning pretty much a reality in the location.



posted on Jan, 4 2016 @ 05:47 PM
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a reply to: roadgravel

That's what happens when you trust your body more than your instruments. That's why somatogravic illusion is so dangerous.



posted on Jan, 4 2016 @ 06:39 PM
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a reply to: Zaphod58

That's why I prefer to fly on the DC 3.

Obviously.............I don't fly very much.



posted on Jan, 4 2016 @ 06:42 PM
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a reply to: Zaphod58

Wait a minute. Since you're the expert on all things aviation, which aircraft has a better safety record?
The 737 or the 707? (you're probably one of the very few on ATS who knows what a 707 was).



posted on Jan, 4 2016 @ 06:52 PM
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a reply to: TonyS

Hard to compare the two, but the 737 if you go just by numbers. The 737 is the most popular short/mid range aircraft built, while the 707 was a long range transport, built in much lower numbers. Although if you add the military aircraft in, the 707 has a really good safety record.

There were just over 1,000 707s built for commercial use between 1958-1979, with 246 accidents, and 172 hull losses, and just over 3,000 fatalities. On the other hand, there have been, as of November 2015, 8,807 737s produced since 1966. There have been 368 accidents, with 184 hull losses, over 4,800 fatalities.

Interestingly Boeing did a study of the various types, and found that the original 737 series had an accident rate of 1.75 per million departures, the Classic was at 0.54 per million, and the Next Generation at 0.27 per million.



posted on Jan, 4 2016 @ 07:52 PM
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a reply to: Zaphod58

Why would the captain add power if he believed the autopilot was engaged. Wouldn't the autopilot have handled that?

-dex



posted on Jan, 4 2016 @ 07:56 PM
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a reply to: DexterRiley

Most pilots I know fly the takeoff and landing with the throttles on manual, so they can fine tune them by feel rather than letting the system do it. They'll do the climb on autothrottle, and up to the final approach, but portions of those phases are done with just the autopilot on, not the throttles.



posted on Jan, 4 2016 @ 08:06 PM
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a reply to: Zaphod58

Didn't they look out the window? Surely something would have appeared wrong?

Is this an example of our over-reliance upon technology? Seems so to me. At least in part.



posted on Jan, 4 2016 @ 08:08 PM
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a reply to: seagull

Evening/night landing, with a low ceiling, light snow/rain at the time. There was nothing to see, which is how they became so disoriented.



posted on Jan, 4 2016 @ 08:13 PM
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a reply to: Zaphod58

Ah, gotcha.

I once had the "pleasure" of sitting in the cockpit of a bush plane in Alaska flying into conditions much like that... The pilot had like a million hours in that type of aircraft, so he made it look easy.

A flyin' Beaver



posted on Jan, 4 2016 @ 08:17 PM
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a reply to: Zaphod58

I read in your OP article that the Russian Aviation people tested several pilots from their various air-carriers on their ability to handle a situation like this.

These tests, carried out in December 2014, showed that only one-third of the pilots completed the missed approach procedure correctly. The exercise also revealed that the pilots had difficulty in answering questions relating to the logic of the autopilot, flight-director, and auto-throttle during an approach and go-around.

“This reflects both a lack of the necessary level of knowledge, and a gap between theoretical knowledge and practical skills,” says MAK.
OP flightglobal.com link

Is it possible that this is another example of the aircraft pilots becoming too dependent on automated systems and forgetting the basics of manually flying a plane?


-dex



posted on Jan, 4 2016 @ 08:23 PM
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a reply to: Zaphod58

Strange, isn't it. We hear all the time its safer to fly than it is to make the drive to the airport. I made 10 uneventful transatlantic flights on the 707. 6 on the 747. I was forced (as a passenger mind you) into an emergency landing on a Braniff operated DC 8 when it experienced engine failure on a flight to New York. I was crash landed into the Luxor Airport in Egypt aboard a Fokker Friendship F27. I experienced a horrible "Carrier" type landing in Tunis aboard a TunisAir Caravel III in which a stewardess was injured when the overhead bins flew open. (The aircraft was grounded due to damage and we had to wait for a replacement).

But every near accident I've been in (except the Braniff flight) has been due to pilot error. The EgyptAir pilot hit the runway wrong and couldn't regain control and had to power out and make a second pass. The TunisAir pilot came in too hot and tried to compensate by going into a steep dive. I've also experienced that "Carrier" landing twice with old Continental Airlines 737 flights; one in Houston and one in Pensacola. I don't know what those guys were thinking.

The absolute, all time, incredible, best pilots I've flown with were TWA and Pan Am on Transatlantic flights back in the 70's and 80's. They could land a 707 or a 747 without the passengers ever knowing touch down had occurred. Smooth as glass! Absolutely PERFECT landings. Another pilot that did that was an Iberian Airlines pilot on a flight from Barcelona to Madrid in, yes..............a DC-3. He landed that plane like a feather! Smiles all around. No bounce, no hop, no "pound down"......a perfect landing. I would give my eye teeth to fly in a DC-3 again.

In summary, I'd say this about my airline mishaps. I've never again flown on a McDonnell Douglas Jet Aircraft.
I would happily fly again in a Fokker Friendship F27, (if it can survive an Egyptian Airline pilot, it can survive anything, although the left wing landing gear suffered damage.........he still took off and flew it out of there).
I've flown Airbus and would say, they strike me as the equivalent of a Chevy vs. Boeing's "Lexus".
I would never again fly in a Caravel III.

And if I won the lottery............I'd BUY a DC3! (And I'd hire a retired Pan Am pilot to fly it)!
edit on 4-1-2016 by TonyS because: clarity



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