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Jetstar pilots forgot to lower the landing gear
- ademarre 7y agoThis story could make a good anecdote to remember when considering human factors, user interface, and checklist design. > Investigators said that because the pilots flew the second circuit at 1500ft, the Electronic Centralised Aircraft Monitor (ECAM) had not reset on the second approach and it did not display a landing memo at 950ft. “The absence of the landing memo should have prompted the flight crew to perform the items of the landing checklist as a ‘read-and-do’ checklist,” it said. Like the lock icon in a browser’s address bar, it is not effective to rely on the user to notice the absence of an indicator.
- rasz 7y agoAirbus already covered this with "master warning message triggered at about 700 ft".
- eps 7y agoThis part looked odd indeed. I'd expect that the aviation industry be very much aware that relying on people noticing that something is NOT there is error-prone. But they did have several backup options, so even if the crew inadvertently managed to work around the first one, the second one (700ft warning) worked as expected.
- t0mas88 7y agoProcedures are designed to do things always at the same time, triggered by something else. The human brain is great at making those connections. For example, on takeoff the pilot monitoring watches the instruments and reports "positive rate" (means "we're climbing from the runway in a stable manner"), as pilot flying you always command "gear up" at that point. It is quite common in simulator practice to get an engine failure right after takeoff, and the most made mistake is forgetting to command gear up, because you're handling the emergency right at the moment you would normally do it. Luckily (as described in the article) you would normally run a checklist after any of these events, and usually that makes you catch the mistake.
- tyingq 7y agoCould they do something like an obnoxious alert if the flaps are out but the wheels aren't down?
- praptak 7y agoI believe there is one already for being too close to the ground when the gear is up ("PULL UP, PULL UP").
- FabHK 7y agoThe level of obnoxiousness is hard to get right. Here, two pilots land a small plane gear up, even though a loud warning horn is sounding throughout. https://www.youtube.com/watch?v=5McECUtM8fw https://www.youtube.com/watch?v=5McECUtM8fw
- t0mas88 7y agoThere is, but it's smarter than that, because you normally start to use the first states of flaps (and slats, at the front of the wing) before putting the gear down. The terrain warning system is aware of where airports are and will also call "too low, gear" if you're approaching an airport without the gear down.
- tyingq 7y agoInteresting. So it's likely there was some kind of warning/alert to the pilots for this incident?
- t0mas88 7y agoYes it says in the article they got a master warning. That's a big red light in the center of their view accompanied by an alarm sound. The terrain warning system comes on after that if you still continue and will keep making the "too low, gear" announcement continuously on a loop unless there is a higher priority problem (engine on fire)
- nutcracker46 7y agoYou have to love the ECAM. On the Boeings, pre 787 at least, we were trained to configure first, look and make sure the flaps, slats, and gear actually extended, then pilot flying calls for the checklist. Do-and-read. Of course, if you have malfunctions or you've got too much shit going on (non-normals, traffic, wx, you're sleepy and screwing up, one or both pilots are not performing well), it would be smart to slow the situation down and revert to read-and-do. It sure is nice to have an obnoxious horn and also GPWS that will start screaming "Too low, gear!!" if the pilots press on without the wheels down.
- tpmx 7y agohttp://avherald.com/h?article=4b8fda93&opt=0 http://avherald.com/h?article=4b8fda93&opt=0
- WalterBright 7y agoThis is why there are checklists for everything. Even the best pilots omit things when checklists are not used.
- WalterBright 7y agoThe incident also suggests to me that there isn't an easy way to check that the airplane is configured properly for landing. A pilot should be able to tell at a glance that it is right.
- t0mas88 7y agoOn a modern type like the 777 there is an easy way to do it. You can call up the checklist on the screen and it marks everything that's "done" as green. So essentially you press the button, and all should be green.
- WalterBright 7y agoThat is better. One thing they learned with airplanes is to set up the gauges so that when things are good, the needles all point in the same direction, regardless of what they were measuring. This made it easy for the pilot to scan the instruments. Later they added green, yellow, and red indications so an out-of-normal indication showed yellow, and really bad showed red. Something car manufacturers still haven't cottoned on to.
- dsfyu404ed 7y ago>Something car manufacturers still haven't cottoned on to. For racing applications it's pretty common to have a multicolor LEDs as backlight for your gauges so your whatever gauge turns red when the reading is bad. For normal cars the goal is totally different. They want to give you the minimum information needed to operate the vehicle and only alert when something is critically wrong. This is why proper oil pressure gauges went the way of the dodo in most vehicles.
- _s 7y ago
- aussiegeek 7y agoATSB investigation https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-042/ https://www.atsb.gov.au/publications/investigation_reports/2... Which points out that the incorrect configuration was on their second go around
- yitchelle 7y agoShouldn't some of the landing procedure, such as lowering of wheels, be instigated automatically?
- t0mas88 7y agoNo, that would kill pilots. If you put the gear down, the drag increases greatly so if you do that during approach it increases the rate of descend significantly. If it does that while the crew is distracted (why else would they forget the gear) you're putting them in an unstable situation, close to the ground, descending rapidly. The current warning is fine. After what this crew got, if you still continue, it will literally shout "too low, gear!" at you in a continuous loop.
- rcthompson 7y agoNo, I'm pretty sure lowering the landing gear can change the aerodynamic properties of an aircraft pretty significantly. You wouldn't ever want that to happen unexpectedly.
- WalterBright 7y agoYou'd be right. Next time you're flying, pay attention when the gear goes down. You'll hear an increase in wind noise, coupled with more vibration. The airplane will also kinda "sag" from the increased drag.
- burfog 7y agoIt would be interesting to deploy the nose gear only when the main gear is in contact with the ground. You'd get better aerodynamic properties that way, because you'd never fly with the nose gear down.
- freehunter 7y agoBut in that case if the nose gear fails to deploy you're likely past the point where you can throttle up and try again. If you try to lower the gear while you're still in the air and the gear doesn't go down, you can circle back and try again.
- starpilot 7y agoOther times this has happened: Qantas https://forums.jetphotos.com/forum/general-discussion-forums/aviation-safety-discussion-forum/50064-qantas-pilots-forget-to-lower-landing-gear https://forums.jetphotos.com/forum/general-discussion-forums... El Al https://www.timesofisrael.com/el-al-pilots-nearly-try-landing-with-wheels-up/ https://www.timesofisrael.com/el-al-pilots-nearly-try-landin... IAF https://indianexpress.com/article/india/chandigarh/when-an-an-32-did-a-belly-landing-because-pilots-forgot-to-lower-landing-gear-5780076/ https://indianexpress.com/article/india/chandigarh/when-an-a... Jetstar, 2012 (!) http://www.digitaljournal.com/article/323319 http://www.digitaljournal.com/article/323319 Once this 737 MAX stuff dies down, we'll probably stop seeing every pilot fart or hiccup reaching the front page. Pilots make mistakes, they always have and always will, we just haven't seen them reported as much. Commercial aircraft are still as safe as they ever were.
- t0mas88 7y agoIt's not a very big deal. In pilot training the common saying is "there are those that have forgotten the gear, and those that will", nobody is immune, you will forget it once at some point. Luckily it beeps at you loudly when you do :-)
- FabHK 7y agoHere, two experienced pilots land gear up (in a small single engine machine) even though it beeps loudly... https://www.youtube.com/watch?v=5McECUtM8fw https://www.youtube.com/watch?v=5McECUtM8fw
- RealityVoid 7y agoThat is amazing. I wonder why they did not react to the obvious beeping. They seemed to just shrug it off.
- danaliv 7y agoGear warnings are the “this website is insecure, are you sure” of aviation. They go off for all kinds of dumb reasons. You learn to tune it out whether you want to or not.
- sillysaurusx 7y agoThe history of flight is so interesting. Did you know that early flights were mostly postal runs? The mortality rate was something absurd. You pretty much got into the profession because you loved being a bird more than being alive. One of the earliest telemetry systems was a beacon where you can only tell how far away you are from it. Like, you know you're X miles away, and you can see X increase or decrease. But you had no indication what direction it was in, or any of the miracles we take for granted today. So they would set up a path of these beacons, and you would fly from one to the next, and that's how you'd know where you were going. I want to say "at night", but honestly I am probably misremembering some of the fascinating details. But the point was, you were often navigating using primitive instruments that gave you very little data about how not to die within the next N minutes. From the title, I thought the plane had accidentally landed with the gear up. But no, a master warning kicked in and the worst that happened was... they pulled up and went around. Woo. but it really is woo. It's so fucking cool that humanity as a whole went from no flight to safe flight in one human lifespan. One old guy's worth of life! Modern civilization is only a few thousand generations old, and we're going from ground to air to air-but-safe in the blink of a slice of a microsecond of human evolution, relatively speaking. I wish I'll be around to see it happen for space travel. SpaceX is coming tantalizingly close, yet space-but-safe is a different matter entirely. I think it will take a few generations for us to work out those problems.
- puranjay 7y agoWhen I look at the early history of flight, I find it so fascinatingly absurd that inventors simply jumped from high cliffs on the *promise" that their invention would work. No one else had mastered human flights. Designs similar to theirs had failed in the past. Yet these people just...jumped. Talk about commitment and belief!
- WalterBright 7y agoNot many tried that technique. The Wright Bros were very concerned about their personal safety and went to considerable lengths in their experiments to be safe.
- bobnamob 7y agoAs a somewhat related aside, Jetstar pilots are currently pursuing industrial action with relation to poor working conditions.
- Jemm 7y agoTime to remove meat bags from control of aircraft
- JshWright 7y agoYeah, computers have never flown an airplane into the ground... /s
- gumby 7y ago> The captain elected to remain at Flaps 3, which investigators described as permissible and safe but not Jetstar’s standard configuration for a visual circuit. This surprised me (I’m a naive non-pilot). I guess I assumed that things like this would be decided by manufacturers and regulatory agencies, with (as happened here) pilots making on the spot decisions. I had not realized different companies might make different safety protocols. Is that common?
- t0mas88 7y agoYes, so common that every airline has it. They're called SOPs, Standard Operating Procedures, which is how the company wants you to fly the aircraft. They're based on manufacturer recommendations / procedures, but do differ per airline. SOPs are very detailed, down to the level of the things each pilot says and how the other responds. As an example: "80 knots" is said by the pilot flying when reaching that speed on takeoff, the other pilot verifies and says "checked", or "abort" if the speed on their side is not the same. You don't say "hey Bob, mine is different", you say exactly what the SOP prescribes. It makes it possible to fly with every other pilot from the same company. Usually pilots don't know each other before the start of the trip. It's safe because everyone does everything in exactly the same way.
- skellera 7y agoAirlines are essentially allow to have their own Operating Handbooks. So they may have different procedures for certain things. I’m pretty sure the manufacturer would say if something wasn’t going to work on that aircraft.
- upofadown 7y agoThis was a situation where the automation normally prompted the pilots to check the gear. The automation failed to do this in a timely manner so that they had to go around. The distraction argument didn't really make any sense at all to me. They were not distracted, they were flying the aircraft. The UX moral here is that if you have a system that always prompts the user then you have to live with the fact that failing to prompt will almost always result in failure to act.
- erokar 7y agoWhile not abnormal, performing a go-around with a visual circuit landing shortly following is a high stress situation. The argument is likely that the pilots were distracted/overloaded by the tasks they had to perform in short order, while maintaining situational awareness.
- aeternum 7y agoIt's still not a good excuse. While a go-around might be higher stress, ATPs should have performed thousands of them as part of their training.
- supernova87a 7y agoIt is a major accomplishment of modern commercial aviation that now, a gear-down error + missed approach qualifies as a noteworthy safety catch. Aviation safety has come so far in 50 years. I have read that the frequency of major safety incidents is so rare now that detection and diagnosis of errors has had to go farther and farther "upstream" towards monitoring and detecting the potential contributors to eventual safety problems. There just are almost no more accidents to study each year. A non-stabilized approaches is itself now cause for study. Truly admirable.
- sbuttgereit 7y agoSounds like it's the sort of thing being discussed in this video... https://www.youtube.com/watch?v=iigjodCiK0g https://www.youtube.com/watch?v=iigjodCiK0g Early, setting the thesis of the video, "...these [loss of control] accidents always follow a pattern. The pattern is: an event occurs, the event causes distraction, distraction causes loss of control." While not exactly loss of control, it certainly sounds similar and seems to follow that central thesis.
- notoriousjpg 7y agoInteresting timing that this gets released 2 days before they are due to take industrial action/strike... https://www.abc.net.au/news/2019-12-11/jetstar-flights-cancelled-amid-pilot-pay-dispute-strike/11788670 https://www.abc.net.au/news/2019-12-11/jetstar-flights-cance...
- turowicz 7y agoThe world is full of airplane incidents. Check this out: https://avherald.com/ https://avherald.com/