Experienced pilots make wrong decisions

Approaching stall at FL220

Interesting and relevant reading these days.

This is an example to illustrate that even very experienced pilots can make wrong decisions in flight.
Luckily they had altitude and there was no loss of separation with any aircraft. 15 passengers recieved minor injuries.

image

Photo credit: Seth Jaworski

Airline: Qantas
Aircraft: Boeing 747-400
Location: Near Hong Kong
Date: April 7 th, 2017

Here is a short summary:

  • Stick shaker activated multiple times (approaching stall) in a holding pattern

  • Speed too low for the altitude (222 kts IAS at FL220)

  • Did not know how to use/understand FMC

  • Missing call outs from pilots

  • Altitude selector not activated

  • Decended below cleared level

  • Lack of knowledge/training

Crew:
Captain, ATPL (Pilot flying) More than 24000 flight hours
First Officer, ATPL more than 16000 flight hours
Second Officer, CPL more than 8000 flight hours

I’m kind of shocked knowing this happened to such an experienced crew in the safest airline of the world.

What do you think?

Full report

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Oh close, Qantas! lol

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Hey, it’s 7 AM here lol. I have corrected it

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Looks like flying becomes an automatic thing. A minor incident can ruin that path in your head.

It’s like being asked the code to enter your flat and not having any idea what it is, yet later you will type it with no problem like you do all the time.

Maybe the crew was too confortable and had no incident like a shaking yoke for their whole career and got marked by that, making these habits disappear…

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It happened about a year ago…so not really cutting edge news…

Probably some shower thoughts haha

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Well, the final ATSB report was released yesterday.

Edit: And the relevance is the discussions about low hours flight crew in the light of recent accidents.

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I do remember this incident and wondering when the report would be out, but do be honest, I completely forgot about this event over the past two years.
Thanks for notifying about the report, I was gonna suggest adding it to the original thread but then remembered that it was two years ago and is closed

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These are facts. Read the report from ATSB.
No hate involved.

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Just so you know, it was on the news. Here is a recent article about it. :)

For the most reliable facts, read the report.

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Hmmmm.not sure about this…this would have made world headlines or at least would have spread around the world - never heard of it until today.

As I have mentioned, ATSB report was released yesterday. So it’s not old.

It is legit, just so you know. :)

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Interesting that it doesn’t mention anything about flight times, duty times, previous rosters or sleep patterns isn’t it?

Does this ring a bell? Mistakes made when you’ve just got up? Tired? Long day at work etc?

Fatigue, and I don’t mean being tired but fatigue, the long term effect of lost sleep patterns and long, non circadian, work patterns can creep up on anyone but, in my industry, it’s far more common than normal.

This whole scenario reeks of tiredness and fatigue inducing cognative failures, ‘we are entering the hold so must be at 220kts…zzzzz’. Followed rapidly by a startle factor leading to incorrect application of technique.

Ultimately the pilots, and very experienced pilots they are too, have to shoulder some of the blame however perhaps digging deeper into ‘cost driven’ rostering practices might allude to some valuable information and lessons.

Pilots are expensive for companies and pushing them constantly to fatigue limits will only lead to a rise in these sorts of incidents as tired flight crew pilot heavy machinery into all countries of the world.

Just a thought.

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I agree with your thoughts. Many aviation incidents/accidents occur because of fatigue. I believe the competition in the aviation industry nowadays is the strongest contributor to this.

That being said; With a crew that experienced and even with an extra pilot on the flight deck it surprises me that they couldn’t understand what was going on.

I know, it’s easy to be an armchair pilot

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Complacency kills.

Can you please elaborate? Thanks

Now Qantas that surprises me!

Although that can happen anywhere, it just shocks me that the worlds first or second safest airline would allow this to go on.

Certainly doesn’t look to me the safest, only the luckiest

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High altitude stalling is a pretty serious thing. A stall is directly related to the angle of attack of the wing hence, in a low speed, descent the nose up is ‘high’ and the FPV will be below the horizon. The difference between the two is the effective AOA.

Upon recovery of a swept wing heavy the idea is to accelerate the aircraft and recover normal flight with as little height loss as possible.

At high altitudes however the FPV can take a long time to ‘climb up’ after the initial speed recovery and any attempt to recover the nose to the horizon too quickly will cause a divergence again from the nose up attitude and the FPV position resulting in another stall warning!

This, as stated, is something that is massively affected by altitude and has to be trained in the simulator. It requires a very gentle and ‘measured’ recovery. Something that can be over ridden by the sudden desire to recover from a situation you most definitely weren’t expecting!

No pilot ‘allows’ it to happen but we can all learn from the unfortunate experiences of others!

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I read through the full ATSB report and found this mentioned about fatigue:

«The investigation assessed whether the captain or first officer were experiencing a level of fatigue known to have an effect on performance. The ATSB found no indicators that increased the risk of either crew experiencing this level of fatigue.»

ATSB report

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