Jump to content

[EN] Piloto ignora pane em motor do 737 e continua o voo até Praga


Recommended Posts

Smartwings 737 captain 'hid' engine failure to continue flight to Prague
By David Kaminski-Morrow

25 July 2020

Czech investigators have revealed that a Boeing 737-800 captain misled air traffic control over a serious engine failure and ignored the first officer’s urging a diversion, in order to press on to Prague, the flight’s original destination.

Investigation authority UZPLN states that the captain’s poor decision-making – disregarding several crucial safety aspects, including the fuel situation – “endangered” the Smartwings flight from Greece’s Samos airport on 22 August last year.

About 20min after take-off, as the aircraft reached 36,000ft, its left-hand CFM International CFM56 engine began to lose power and flamed out.

The first officer, who was flying, knew the aircraft needed to reduce altitude quickly and sought assistance from the captain to advise air traffic control.

But rather than making a ‘pan pan’ urgency call, the captain delayed communicating and then merely informed controllers of a “technical problem”. The aircraft remained at 36,000ft – its airspeed declining to 226kt – for about 2min before it commenced a descent to 24,000ft.

As the 737 descended its airspeed increased to the 310kt needed to attempt a windmill restart of the engine, but this was unsuccessful. About 10min later a second restart attempt was performed using cross-bled compressed air.

While the crew reported the shutdown of the engine to its operations control, the captain did not advise any air traffic centre of the engine failure – leaving controllers unaware that the 737 was proceeding to Prague at 24,000ft on just one engine.

Instead of landing at the nearest airport the 737 proceeded to Prague on one engine

The jet passed through the airspace of Greece, North Macedonia, Serbia, Hungary and Austria before entering the Prague flight information region, at which point the crew transmitted a ‘pan pan’ urgency call, notifying controllers of the single-engined operation, and seeking a “short-cut” to land.

UZPLN found the crew had planned to avoid refuelling in Samos, by carrying sufficient fuel for the return trip to Prague.

The aircraft had 9,460kg of fuel on board after landing at Samos, and the on-board systems indicated that 9,217kg was required for the return.

But the engine failure and the lower altitude affected the fuel calculations. The inquiry says the captain “did not perform” the proper performance calculation to determine single-engine cruise altitude capability, which should have given a level of 22,000ft.

When the 737 landed at Prague it had 2,435kg of fuel on board, just 23kg above the reserve fuel figure. The inquiry states that, with such a small difference, the captain could not have been sure that the jet would not have been burning reserve fuel – the sum of the alternate and final reserve – by the time it reached Prague.

The investigation catalogues several hazardous decisions by the captain, stating that he “concealed” the engine failure to several air traffic centres and “ignored” rules to transmit a ‘pan pan’ urgency message which would have enabled controllers to resolve possible traffic conflicts in an area of airspace where reduced vertical separation minima applied.

UZPLN describes a toxic cockpit atmosphere. The highly-experienced captain, with over 8,000h on type, failed to follow cockpit resource management principles to solve the problem. He did not discuss safety issues of the situation with the first officer, who had nearly 2,500h on 737s, but instead used the steep authority gradient to push through his poor decisions.

The captain’s behaviour contrasts with that of the first officer who, according to the inquiry, believed the continuation to Prague was “illogical” and “repeatedly” tried to highlight the requirement to land at the nearest suitable airport, maintained situational awareness, and cross-checked procedures – despite the captain’s performing them “unusually fast”.

But he was flying the aircraft under an “enormous” power gradient, it adds, given that the captain held flight instructor and examiner qualifications, and had a senior position with the airline.

“[The first officer] did not contradict the [captain’s] decision to proceed to [Prague] over concerns that this would worsen the crew co-operation necessary to complete the flight,” the inquiry states.

UZPLN has tried to explain the captain’s extraordinary deviation from the safety regulations, given his experience and knowledge, stating that his actions during the flight were “difficult to understand”.

The inquiry could not prove that the airline’s management culture influenced the captain’s decision-making, nor that the captain was affected by economic considerations that arose from the engine failure.

“It is therefore not possible to rationally conclude why the [captain] had a [conflict] between complying with established obligations…and his personal decision to continue, with one non-functioning engine, to the destination,” it adds.

The captain defended his thinking to the inquiry, testifying that he believed his flight experience had been broad enough to assess all the risks associated with his decisions.

He added that Prague was effectively designated as an alternate, and that Budapest would serve as an alternate to Prague. The captain said that Thessaloniki and Belgrade were ruled out as diversions, and Vienna was discounted owing to traffic.

Cockpit-voice recordings were unavailable to the investigation, as the data was not downloaded.

Investigators also point out a number of other shortfalls during the flight, including a failure to comply with a safety bulletin regarding engine settings before departing Samos.

None of the 170 passengers and six crew members was injured during the event. The aircraft involved was OK-TVO.

https://www.flightglobal.com/safety/smartwings-737-captain-hid-engine-failure-to-continue-flight-to-prague/139486.article

Link to comment
Share on other sites

Pelo que a investigação descreveu, pareceram-me ótimos subsídios para uma boa sessão de EBT (Evidence Based Training) no simulador. Honestamente, que loucura.

Ok, são apenas fragmentos deste evento, mas independentemente das razões, não é uma opção da tripulação de uma aeronave com 2 motores, quando um deles torna-se inoperante ou não produza potência compatível com todas as fases de um voo, pousar no aeroporto mais próximo em termos de tempo de voo e que apresente condições aceitáveis de operação para o tipo de aeronave, mas uma exigência de regulamentos, compatíveis ao tipo de operação da empresa, que possivelmente, no caso, deve corresponder ao descrito na FAR121 ou regra similar.

Obviamente isso não significa que num cenário como sugerido os tripulantes devem tomar decisões precipitadas ou sem analisar os possíveis riscos quando envolvem múltiplas escolhas. Entretanto, ao não realizar a ação devida, o acúmulo de violações e riscos nos quais a aeronave pode ficar exposta eventualmente vão extrapolar o limite do tolerável. Vale salientar que nesse momento não importa se é um 737 ou um 777, o procedimento será o mesmo, ainda mais quando não se está voando em regime EDTO (ETOPS). 

Em qualquer circunstância de anormalidade, a prioridade sempre deve ser 'voar o avião', enquanto o problema é administrado, e a partir do instante que as condições permitirem, envolve-se o controle de tráfego aéreo. A escolha dos termos Pan-Pan ou Mayday é opcional, pois fica condicionada ao contexto, mas o que não pode acontecer é hesitar em se manifestar, porque a partir do momento que o ATC é incluído no processo, melhores são as chances de coordenação e tomada de decisão. 

Entende-se como aceitável o prolongamento do voo além de pousar no aeroporto adequado mais próximo, se todas as alternativas apresentarem condições adversas e/ou inseguras para a situação, mas jamais colocar como prioritário ou até mesmo como opção buscar um local que atenda aos interesses da empresa, por causa de um melhor suporte em solo, de um modo geral.

Num 747 a tomada de decisão pode ser 'legalmente' diferente, e sendo assim, alguns anos atrás uma tripulação, operando um trecho entre LAX e LHR, decidiu continuar o voo ao destino, logo após 'perder' um motor na decolagem. Existiam claros sinais desde a tomada de decisão que o avião nunca pousaria nem na Piccadilly Circus dentro da margem dos regulamentos. No final, tiveram a sorte de alcançar com as calças nas mãos Manchester, após cruzar trimotor os EUA inteiro + o Atlântico Norte. 

Na aviação sempre aprende-se alguma coisa, como nesse episódio apresentado. 

Link to comment
Share on other sites

Smartwings 737 inquiry recommends psychological appraisal of captain
By David Kaminski-Morrow 26 July 2020

Czech investigators probing the incident in which a Boeing 737-800 proceeded to its destination without diverting, despite suffering engine failure early in the flight, have recommended that its captain should undergo psychological assessment.

Investigation authority UZPLN says the unusual recommendation for a psychological examination at the Czech Institute of Aviation Medicine results from the captain’s “persistent conviction” that he performed decision-making processes correctly during the Smartwings flight from Samos to Prague last 22 August.

After the aircraft’s left-hand engine flamed out, some 20min after take-off, the captain opted to continue the flight to Prague – flying for some 2h 20min at reduced altitude on a single engine, without fully informing air traffic centres of the situation, and landing at Prague just before the jet started burning reserve fuel.

UZPLN has highlighted, in its newly-published final report, several safety concerns over the decisions made by the captain, who violated standard procedures while ignoring guidance from the first officer.

After the engine failure, marked with a cross, the aircraft continued its flight to Prague

None of the 176 occupants was injured but Czech civil aviation authority UCL had publicly stated at the time that it would take action – administrative or legal – if rules had been breached.

Following a UCL recommendation Smartwings removed the captain from duty a week after the event, and UCL also pressed for the captain’s resignation, as a precaution, from other executive positions at the carrier. The airline removed the captain from these executive functions a few days later.

After being subjected to a preliminary ban on acting as pilot-in-command on a commercial aircraft, the captain appealed to the Czech ministry of transport which cancelled the ban.

But the administrative measures were subsequently put on hold after Czech police began looking into the incident, requesting documentation from UCL, before informing the authority in October that a criminal probe was under way. The status of these proceedings is not clear.

UZPLN has recommended that UCL checks Smartwings’ compliance with operating procedures laid down by Boeing.

UCL director David Jagr says the authority will “carefully evaluate” the investigators’ findings. But he points out that, after a technical audit and several months of effort on a corrective action plan, a check on the airline’s operations in late May showed “significant improvements” and no outstanding concerns. The assessment work was completed on 17 June.

https://www.flightglobal.com/safety/smartwings-737-inquiry-recommends-psychological-appraisal-of-captain/139487.article

Link to comment
Share on other sites

Archived

This topic is now archived and is closed to further replies.

×
×
  • Create New...

Important Information

Saiba os termos, regras e políticas de privacidade