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    Thread: The Lesson We Learn from BIRGENAIR FLIGHT ALW-301

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      Exclamation The Lesson We Learn from BIRGENAIR FLIGHT ALW-301

      Introduction

      One of the tragic accidents in the aviation history is the Birgenair flight ALW 301 which no survivors has found throughout the horrible nose-down attitude impact of the aircraft on the water of Atlantic Ocean on February 6, 1996. The flight is using a Boeing 757 – 225 and is known as a fully computerized and modern unit at that time and preliminary investigations and speculations to the accident is the unmanaged ground maintenance, also note that the B-757-225 in flight ALW- 301 is a 1985 model which is quite known to the pilot in command based on his records and last training.

      That accident is counted a 3rd loss and 3rd fatal accident in the history of Boeing 757 models and holds the 2nd worst accident in Atlantic Ocean in 1996, the accident shakes the whole media and news at that time and many critics questioned the safety of flight and the foundation of the Boeing company as the accident event hold the 4th worst accident in the company up to now in 2020.

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      Numerous investigations are done because the aircraft is smashed in pieces when it dives the water in a horrible angle that also make the investigators to conclude that no passengers as well as the crew will ever survive the accident. At the end of investigation, it is announced that all the 176 passengers and the 13 crew members died. The aircraft also cannot be retrieved because according to the report, the result of the impact with the water literally destroyed the whole aircraft to pieces.

      What Happen to the Flight Crash?

      The weather conditions in the Puerto Plata terminal area between 20:00 and 02:00 of its local time shows no sign of wind from the east of southeast. This means that no observed storm cells are forming and precipitation can be expected to interrupt the flight and it is a good sign to make a safe flight based on the given readings and the place is normally safe in terms of flight route and no report of conflict to the travel route in the past flights of the aircrafts.

      The investigation took long because the accident happens in the large body of water and it took investigators a long time to know the cause of the aircraft crashed because the cockpit recording devices submerged in the cold ocean and it is very crucial at that time to recover it because the signals of the cockpit recorders are starting to fade away as time passes because of the damaged it takes in the salty water. Though, it is recovered using the submarine US Navy CURV – Cable Underwater Recovery Vehicle which is a remote type submersible which could work at deep waters and high pressure, greater than the feats of a normal submarine.

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      The investigations prior to the accident is being based on ICAO Annex 13 as a basis on how the investigators and inspectors should make a report detailed by detailed and the speculation and demonstration of the Flight ALW 301 in a flight simulator test will be done to prove the reason of the accident. Annex 13 reflects the “Standards and Recommended Practices covering Aircraft Accident and Incident Investigation” that covers the injured and fatally counts and the damage to the aircraft.

      Retrieving the flight data recorder and the cockpit voice recorder gives the idea that the pitot tubes of the aircraft is being damaged showed the real culprit but it is unfortunate to retrieve the pitot tubes because it is not known where are they in the depths of the water. The investigation team interviewed the ground personnel and the maintenance crew that was assigned in the Boeing 757 -225, particularly to the Flight ALW 301 and totally found some crucial information and some odd things that contribute to the accident.

      The said pilot in command is a 62 years old and one of the Birgenair’s most senior pilots and have 24, 750 hours of flying time, Ahmet Erdem and his last training is on February 12, 1995 in the United Airlines Training Center in the simulator of B- 757 and B – 767 aircrafts. While the co-pilot is First Officer Akyut Gergin with the age of 34 and has 3,500 hours of flying time but the major issue here is that those flying hours are not essentially flights using B-757-225 and based on the records, he is entirely new to the Boeing 757 with a record of less than 70 hours of flying time. A relief pilot is also assigned on that aircraft which is Muhlis Evrenesoglu and his age is 51 and with his record of 15,000 hours of flying time but unfortunately, he is also new to the Boeing 757 variant. It is quite possible that the combination of the three can’t handle emergency situation where one of the pitot tubes is faulty, the air speed indicator shows abnormal readings, the right decision of a sudden nose-down, sudden alarms and warnings that mainly lead the whole people and the aircraft to its crashing state.

      It is noted by the investigators that the First officer and the Relief Pilot don’t say any recommendation or better action in that situation mainly because of the seniority of the Pilot-in-command who is mainly trained in B-757 aircrafts and the flying hours of experience is showing the huge gap of the two to the pilot so the investigators conclude that they mainly trust the pilot-in-command so in the first scenario where the faulty air speed indicator of the commander shows up before the take-off, they just follow the given order to continue to take off.

      Misunderstanding is the one that destroys the flight and the misjudgment of the captain that both his and the First Officer’s airspeed indicators were wrong, not knowing that his air speed indicator is the faulty one because his pitot tubes are blocked by something which the investigators assumed that an insect’s nest is the one blocking the tubes. They conclude it after the investigators interviewed the maintenance crew and they gathered data that the aircraft had not operate in 20 days and only two days before the accident is where the pitot tube covers were removed to conduct an engine test run.

      The investigators also speculated that when the Captain’s airspeed indicator seemed to start working during the takeoff, the indicator was actually showing altitude changes and because of the blocked pitot tubes, the thinning of the atmosphere cause the air inside the tubes to expand and building stress and pressure which makes the airspeed indicator to show abnormal readings prior to the recordings and the cockpit voice recorder. The worst scenario is when the autopilot is activated and the only thing it follows is the air speed indicator of the captain which is why the airplane computer decided the best action based on the readings which is why the airplane become unstable cause of the rapid changes of the faulty air speed indicator of the captain. The bad thing to the autopilot system is that it can’t detect sudden changes in the readings that is obviously a malfunction in our eyes, so when the airspeed was indicating that the plane was having a high speed, the action of the autopilot is to pitched the nose up in an attempt to decrease the speed of the aircraft.

      Alternatives to Prevent the Accident!

      The plane crash would have been prevented if the ground personnel and the aircraft maintenance crew has been aware that the aircraft have been on the ground and not operating for 20 days so the risk became higher in its next operational flight if not manage and inspected before the day of the flight, and note that 20 days of not flying of an aircraft is a huge amount of allocated time for maintenance, aircraft inspection, and repairs which the ground personnel team neglected. Knowing more of the “Dirty Dozen” is a great tool and knowledge for aircraft ground personnel and maintenance team that can save a lot of lives if being practiced regularly as an oath in their duty and can be associated to ICAO Annex 8 which talks about the airworthiness of the aircraft. The blocked pitot tube that makes the air speed indicator readings unstable is the proof that something blocked the opening of the tubes which the investigations speculated that a wasp nest is being there the whole time, which it might be saved if being checked regularly and that is the downside of what really happens.

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      Aside from the faulty air speed indicator which happens to be the fault of the malfunctioning pitot tube, it is quite noting that the First Officer notice how the air speed indicator of his and the air speed indicator of the captain readings are totally different with a huge gap and not considered just a discrepancy. This is where the turning point of the aircraft if the passengers and the crew will be save or not because deciding to continue the take off even knowing that something is off is the captain responsibility and he should know much better if it is safe to continue the flight based on his hours of flight experience. The captain also said based on the voice recording that “we do not believe them” which pertains to the EICAS, which is terribly bad because those indicators, mean everything.

      The Probable Solution During the Flight

      The very viable solution from the start is to stop the take-off phase after they discover the unmatched air speed readings which makes it the only turning point in this accident. It is very frustrating that the flight crew did not stop the operation of the take-off phase after they noticed the abnormal and unstable air speed indicator of the captain in the first place, though the investigators have a hard time on why they just continue the flight instead of just delaying the passengers in exchange of safety. They review the take-off phase of the Flight ALW 301 and they proposed that it might be the captain and the first officer are concerned about not having enough runway to stop but the measurements of the runway showed that the Boeing 757-225 has more space to take if the flight will be aborted on that phase. This reasoning of a short space to even take-off can be sounded true if they said it in the voice recording but in the cockpit recording, the captain just ignore the abnormalities and just proceed the flight even after confirming that his readings are very different from the first officer’s indicator.

      The Actions of the Aviation Authorities to the Flight Crash:

      The accident is very traumatic to the world of aviation and the fact that no survivors left behind after the crash makes the foundation of trust by the people in flight transportation go weaker at that time but in exchange, it gives the world of aviation more steps to learn and to improve further. In response of that accident, Boeing modified their aircraft AI intelligence and new modified cockpit indicators and warnings when their instrument readings are not matched during the take-off phase. It gives a new reason for improvement of autopilot system that gives the pilot an access on which pitot tube will be use which unfortunately not present feature in the Flight ALW 301.

      Additional recommendations in this accident to never happen again is aviation industry should focus on the countermeasures and preventions of the human factors or the human conditions, such as fatigue, complacency, and stress that which is very essential to a successful flight operation and the aviation maintenance. It is said that human factors directly cause or contribute to many flight crash and failures which is in the recorded database that 80 percent of the repair and maintenance errors and mistakes involve human factors that eventually led to cause worker injuries, flight crash, and the worst case is risking the lives of the passengers in the flight. Investigators in the flight ALW 301 speculated that the flight crews are eager to go home after the flight that affects the decision regarding continuing the flight despite abnormalities of the readings occur in the captain’s indicator. Another human factor is the complacency of the aviation maintenance personnel in regards of inspecting the aircraft, and knowing a 20 days of ground standby aircraft will increase the risk percentage if not proper maintenance is given even if disregarding the hours of experience of the pilot-in-command on the Boeing 757-225.


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