Part 1.04.20 of the ATR72-600 FCOM indicated that when the autopilot was engaged, the pitch, roll and yaw actuators were connected to the flight controls, the pitch auto trim and yaw auto trim function were also activated. According to the CVR from 1041 to 1051, with the exception of performing pre-departure procedures, Captain A (PF) had few additional interactions with Captain B (PM) or the observer pilot. As recorded in the FDR, after the autopilot was disengaged, the PF frequently applied trim control. Incomplete procedure check and execution; Insufficient knowledge of QRH (ENG FLAME OUT AT T/O, BOTH HYD SYS LOSS); Did not fully advance power levers to ramp position during the SINGLE ENGINE APP GO AROUND; Did not follow SOP for ENG FIRE operation while on short final and altitude below 400 feet; and, Cockpit management and flight planning needs. The current technical countermeasures implemented by the engine manufacturer to address the AFU continuity problems were not sufficiently effective and require further solutions. As the aircraft flew over an overpass before impacting the water, its left wing collided with a taxi with two occupants. The engine manufacturer attempted to control intermittent continuity failures of the auto feather unit (AFU) by introducing a recommended inspection service bulletin at 12,000 flight hours to address aging issues. The occurrence aircraft was dispatched at Songshan Airport with no known defects and was in compliance with all applicable airworthiness directives and service bulletins. The FO commenced ATR72-500 transition training on 16 June 2008. Captain A held an air transport pilot license (ATPL) issued by the Civil Aeronautics Administration (CAA) with a multi-engine land, instrument, and type rating on both ATR72-500/600, endorsed with privileges for the operation of radiotelephone on board an aircraft with no limitations and a current ICAO Level 4 English language proficiency. There are different types of aviation headsets used for various purposes. At 1053:00, the PM stated: “okay engine flame out check”. However, TNA flight crew training records showed that the ART72-600 differences training records for all ATR72-600 pilots were not completely maintained by TNA. As the throttle was advanced for take off in the occurrence flight, Captain B (PM) noticed that the ATPCS was not armed and he responded correctly by announcing that. However, when the Captain A attempted the upgrade selection, the selection panel assessing the Captain’s oral test performance comprised only six ATR72 IPs/CPs. At 1052:43 the PF stated: “I will pull back engine one throttle”. However similar information was not documented in ATR’s manuals. Captain B commenced ATR72-600 differences training on 16 December 2013 at the ATR Training Center in Singapore. Another fatal accident involving a TransAsia Airways flight occurred just seven months after the crash of Flight GE222. He completed the initial training successfully on 14 August 2007 and qualified as an ATR72-500 first officer. One passenger received minor injuries. Ultimately the aircraft entered a stall from which the crew were unable to recover. Both OEBs promulgated the same normal take off procedure for ATPCS discrepancies: “At take off, the ATPCS must be checked armed and announced. According to that procedure, the first item was to select ATPCS OFF and bleed valves OFF, which disabled the autofeathering function during take off. Post-impact examination of the engines indicated no pre-existing anomalies affecting their normal operation. Your email address will not be published. The engine manufacturer (P&WC) had been aware of AFU-related technical issues causing uncommanded autofeather events since 2005 and proposed SBs starting from 2007. The remaining 13 passengers and one cabin crew sustained serious injuries. However, the assessment of the pilot’s performance during the full flight simulator (FFS) session on the final day of training noted that the pilot “MAY NEED extra training” commenting “check EFATO (EFATO: engine flame out at take off. The following actions and callouts were required for shutting down an engine (example used is ENG 2): During the shutdown of ENG 1, the flight crew used non-standard processes and callouts in a noisy cockpit environment with frequent stall warnings. The takeoff roll commenced at 1051:39. Lion Air B737-8 (MAX) PK-LQP crash on the Java Sea, 29 October 2018. Three of the upgrade candidates, including Captain A, attended and passed the upgrade ground test on 12 May 2014 before they had completed all the required ground courses. If this condition is met for 20 seconds, the IAS mode automatically disengages and reverts to PITCH HOLD mode). Flight crew coordination, communication, and threat and error management (TEM) were less than effective, and compromised the safety of the flight. The TRB decided to provide Captain A an additional simulator session followed by a simulator re-check between 29 and 30 June 2014. Air Crash InvestigationTransAsia Airways Flight 235(new) Air Crash Investigation (TGL) 1:37. Furthermore, although ATR72 AFM 5.03 has a rejected take off procedure described as an abnormal procedure, it is associated with one engine inoperative condition only, and the rejected take off procedure was not described in the ATR FCOM. However, Captain B (PM) as an experienced pilot did not intervene or take-over to mitigate the absence of leadership from the PF. TransAsia Airways (TNA) did not follow its own procedures when selecting and training pilot flying for upgrade. The occurrence flight crew’s decision was not consistent with these expectations. Visual meteorological conditions (VMC) prevailed at the time of the aircraft’s departure. During the initial climb after takeoff, an intermittent discontinuity in engine number 2’s auto feather unit (AFU) may have caused the automatic take off power control system (ATPCS) sequence which resulted in the uncommanded autofeather of engine number 2 propellers. The source code for the WIKI 2 extension is being checked by specialists of the Mozilla Foundation, Google, and Apple. Those cracks were believed to have caused momentary electrical disruptions leading to an uncommanded autofeather. 3) was removed and sent to the manufacturer for test and examination. However, all of ENG 2’s parameters were normal before the ATPCS sequence was triggered. Part 03.02.03 of the ATR FCTM described the detailed crosscheck procedures and standard callouts for shutting down the affected engine. That is, the pilot met the required performance standard). Single pilot CRM, Unrecoverable deviation from the intended flight path, Loss of flight crew airplane state awarenessÂ. That training comprised six phases: phase one “basic ground training”; phase two “airplane type ground training”; phase three “observation flights”; phase four “simulator training”; phase five “local training”; and phase six “initial operating experience (IOE) line training”. The above maintenance actions were included in the latest CMM version. After retiring from the military, Captain A had joined another local airline in September 2009 as a trainee first officer on the A330. The IAS take off sub-mode guidance primarily maintains the IAS target but also ensures a minimum ascending slope. Browse more videos. Captain of TransAsia Flight 235 mistakenly switched off working engine after the other lost power Findings on the crash that killed 43 come in new report by Taiwan's Aviation Safety Council On the day of the occurrence, the flight crew was assigned to operate two return flights from Songshan to Kinmen. Based on the FDR data and the ATR72 autopilot disengagement logics analysis (see Appendix 14), the Safety Council concluded that the PF disconnected the autopilot when he had taken manual control of the aircraft. Therefore, it seemed more likely that the absence of a formal, documented company policy that was enforced and consistent with the reported ATPCS training on the -600 created an opportunity for misunderstanding. maybe you shouldn’t. It was a cargo flight and neither pilot survived. The operation of the ATPCS would be rendered unreliable if the torque signals transmitted to the system were disrupted intermittently or otherwise. The engine manufacturer has issued a modification addressing the specific finding of this investigation. He successfully completed ATR72-500 transition training in November 2009 and served as a first officer on the ATR72-500 fleet. Air Crash Investigation Southern Airways Flight 242 Delta, Air Lines Flight 191. Fifteen of the 58 people on board were rescued but at least 35 others died. There was no evidence to indicate that the flight crew’s performance might have been adversely affected by pre-existing medical conditions, fatigue, medication, other drugs or alcohol during the occurrence flight. While the PF momentarily delayed any further retardation of PL1, he later continued  to  reduce power  on  ENG  1  which  was  probably not detected by the PM until the stall warnings and stick shaker activated just before the PF shut down the wrong engine without the required crosschecks. However, the PF did not appear to process the information on the EWD. The flight crew’s performance reflected many of the known findings in the “Propulsion System Malfunction + Inappropriate Crew Response (PSM+ICR)” report, U.S. Army study, and other human factors issues identified in the literature. At least 31 people were killed in the crash. The training syllabus comprised adverse weather operations, normal/abnormal procedures, including the roles of PF/PM and other flight crew task sharing, positive transfer of aircraft control, consistent checklist philosophy, emphasis on the priorities of “aviate, navigate, communicate”, correct use of all levels of flight automation, correct crew response to system malfunction/s, and aircraft type systems and limitations. TNA had not implemented a formal process for developing detailed and standardized line-oriented flight training (LOFT) training with specific CRM objectives; Audiovisual feedback during LOFT and simulator debriefings was generally not utilized by TNA IPs. While the manufacturers... Aviation Tribune is a respected source of valuable information about the aviation industry and indexed by all the major news aggregators, including Google News. The available evidence indicated the intermittent discontinuity between torque sensor and auto feather unit (AFU) number 2 was probably caused by the compromised soldering joints inside the AFU number 2. The PM then verified the activation of the ATPCS sequence and called “check up trim yes, auto feather yes” at 1053:02. At the time of the occurrence, TNA pilots who performed unsatisfactorily during training or checking activities were offered remedial training for the specific failure items. TransAsia Airways Flight 235. Sudden and unexpected hazardous events are stressful for flight crews. The abnormal status can be explained by the discontinuity between the AFU No.2 and the torque sensor. The PM initially appeared to comprehend that the propulsion system malfunction was related to ENG 2 but the PF did not have the same understanding of the situation. While he passed the differences simulator check on 19 January 2015, the examiner commented that the FO “will need some time to get used to the 600 (ATR72-600), flying with an experienced captain is strongly recommended.”. 45:33. The PF’s unannounced reductions in power on ENG 1 as a result his confusion regarding the identification and nature of the actual propulsion system malfunction led to the shut down and feathering of ENG 1 propeller. This story was first published on CNN.com, "Captain of TransAsia Flight 235 shut off working engine after other failed: Report." TransAsia suspended operations and shut down indefinitely on 22 November 2016 after a pair of hull loss incidents that occurred within months. The flight crew could have identified the ENG 2 loss of thrust and maintained control of the aircraft if both crew members had shared a correct understanding and recognition of the propulsion system malfunction. Final report, Jetblue A320 engine fire due to the fatigue fracture of a high-pressure turbine stage 2 disk blade, Subsurface Defect on a high-pressure turbine stage 2 disk led to the uncontained engine failure on American Airlines flight 383, Oct. 28, 2016, Uncontained Cargo Fire fed by Lithium Batteries Leading to 747 fatal accident, Pilots fatigue lead to a Danish Air Transport ATR 72 serious incident, Runway Excursion During Landing, Delta Air Lines MD-88, March 5, 2015. Pilot performance in emergencies: why it can be so easy, even for experts, to fail, When the error comes from an expert: The Limits of Expertise, Normalization of Deviance: when non-compliance becomes the “new normal”, The Organizational Influences behind the aviation accidents & incidents, Multitasking in Complex Operations, a real danger, CRM at its best: Qantas flight 32, learning from the recent past, See and Be Seen: Your Life Depends on It. The CAA urgently needs to enhance the surveillance of TNA’s operations and ensure that TNA’s safety improvement programs implemented in a timely and effective manner. The pilot flying did not appropriately respond to or integrate input from the pilot monitoring. The indicated airspeed was 102 knots. That indicated that the PF skipped several required memory items and attempted to shut down ENG 1 when the flight path was not yet stabilized. The Aviation Herald reports that the final report (in Chinese) (summary in English) has been published. Based on the data of the report, GE235 remained in the air for 2 minutes and 40 seconds, but within 45 seconds after takeoff at an altitude of approximately 1,200 feet, the temperature of the gas turbine engine №2 fell (Aviation occurrence report TransAsia Airways flight GE235 2015).Therefore, an automatic feathering of the left engine took place. The Feb. 4 crash of TransAsia Airways Flight 235, which was filmed by dashboard cameras that showed the plane plummeting over an elevated roadway in Taipei, the capital, killed 43 … A review of the aircraft’s maintenance records before the occurrence flight revealed that there were no defects reported that related to engine number 2 automatic feathering system. The aircraft continued to climb and airspeed subsequently decayed even though the PM alerted the PF about the airspeed and called out “okay now number two engine flameout confirmed”. Of ENG 2’s parameters were normal before the aircraft continued to bank to the right.. 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