Boeing Boeing 737 Cargo Plane Ditches off Honolulu

[anorlunda]

That doesn't mean that in general turning around is a better use of time than a restart checklist.

No, you're missing the point of Cockpit (Crew) Resource Management (CRM). The idea is to split the responsibilities. One pilot looks after aviating, and the other can focus on checklists. It is not either or, it is "do both."

In the Eastern 401 crash linked above. All three (maybe 4) people in the cockpit focused on a malfunction, leaving nobody to fly the plane. Out of that accident came the doctrine of CRM.

Flying straight and level out to sea, allowed autopilot while both human pilots focused on something else. Flying circles near the airport would have forced them to split up, with one flying and the other doing something else.

 

[russ_watters]

Clearly in this case it would have been better to have turned around. That doesn't mean that in general turning around is a better use of time than a restart checklist. We don't expect our pilots to be robots, but we don't expect them to be precognitive either: at the time of that message, they had only lost one engine.

Had the outcome been different - say a runway accident with 809 - because they turned back immediately after losing one engine, would we not criticize them for turning back too soon rather than attempting a restart?

No criticism yet, just investigation. We have identified a potential better outcome if a different process (better process) were used (and more than one is on the table*). We don't yet have enough information to determine if either were foreseeable results.

0. Fly straight away from the airport while completing checklists, until...? (chosen option)
1. Orbit near the airport while completing checklists.
2. Return to land immediately without completing any more checklists than can be completed during an immediate return.

*I'm leaning toward Option 1. There's no guarantee that this would have helped. And like you said, Options 1 & 2 also carry risks (landing heavy, for example).

Also, ABCDE is a procedure guideline, not a checklist. As @anorlunda said, running a checklist and deciding whether you should are two different things.

 

[Vanadium 50]

No, you're missing the point of Cockpit (Crew) Resource Management (CRM). The idea is to split the responsibilities. One pilot looks after aviating, and the other can focus on checklists. It is not either or, it is "do both."

If you are saying "Do the checklist, but don't get too far from the airport", I sort of agree. I say "sort of" because of the geography of the area. Have you ever been there? North of the airport, you have highlands in about two miles. East of the airport you have downtown with several buildings over 400 feet. So I see where you might want to avoid that.

I don't know what a 737's turning circle is. Can it do a 360 in two minutes? That would mean it's a minute to turn around, or at 180 knots, 3 nautical miles. I wonder if they were thinking to line the plane up for 8R. (I had to look it up - I'm not that familiar with the airport) I can definitely understand them not wanting to be in the right spot but pointing in the wrong direction.

 

[russ_watters]

I don't know what a 737's turning circle is. Can it do a 360 in two minutes?

A "standard turn" for an airplane under 250 kts (which this one would have been) is 360 degrees in two minutes.
https://en.wikipedia.org/wiki/Standard_rate_turn

[Edit: fixed]

 

[Vanadium 50]

360 in one minute or two?

 

[mfb]

250 kts * 2 minutes / pi = 5 km diameter using the "standard turn" from Wikipedia.

I drew one 5 km and two 10 km diameter circles on the map (from Bloomberg), there should have been more than enough space to fly in circles. The turn towards the airport matches a 10 km diameter pretty well.

 

[russ_watters]

360 in one minute or two?

Oops...should have stopped posting right before bed. Fixed.

 

[anorlunda]

Let's wait for the release of the cockpit voice recorder (CVR) and the black box. That should conclusively tell us if both pilots were focused on the failed engine, or whether one pilot remained focused on flying the airplane.

The CVR may also reveal why at 10 seconds after takeoff clearance, they radioed an intention to return to airport, but 100 seconds later they asked for a delay in returning. That decision can then be compared with their training.

 

[Vanadium 50]

I think @mfb posted a pretty good map. Both the takeoff and the turnaround circles are about 6 miles in diameter. It also looks like they are about 6 miles away from what would be in hindsight the best position, which is not too far off from the famous 87 seconds.

I listened to the ATC again. Much oddness.

• While 810 had a declared emergency, ATC cleared T4 809 to land, and KH 56 to take off. I would have imagined they would have stopped all non-essential operations.
• Boy that poor air traffic controller had a lot to do!
• The plane should have been able to fly on one engine. They start descending right after the first turn, but it's not until after the second turn they say that the second engine is running hot. It looks like it was misbehaving well before then.

 

[DaveE]

While 810 had a declared emergency, ATC cleared T4 809 to land, and KH 56 to take off. I would have imagined they would have stopped all non-essential operations.

It is normal for ATC to continue some operations when handling an emergency aircraft. But, they have to have the bandwidth to do that and make sure not to interfere with the emergency operations. There's usually not a problem landing a plane or two while the other guys are running checklist or in the traffic pattern. They are experts at timing and sequencing operations, they do it all day long every day.

I heard some airline pilots (airlinepilotguy.com) commenting that the busy radio channel was partly the result of the emergency aircraft not clearly declaring an emergency with a "Pan Pan" or "Mayday" call. They said that while pilots are sort of monitoring other traffic comms, they are only really listening for specific stuff that effects them. But, they are hyper sensitive to hearing "Mayday" and they know to shut up and only transmit essential queries if they hear that. Aside from following ICAO standard comms, they said that it is important to clearly let everyone know that we aren't doing business as usual; get everyone's attention first, then you can explain later.

I also recall an ATC guy at JFK say that "Emergency", "Pan Pan", and "Mayday" all mean the same thing to them, they are processed the same way.

 

[Vanadium 50]

Let's wait for the release of the cockpit voice recorder (CVR) and the black box.

Have they been recovered? (And maybe the engines?) They are in a couple hundred feed of water. Too deep for conventional divers, but not inaccessible. Just hard to get to.

 

[berkeman]

Have they been recovered? (And maybe the engines?) They are in a couple hundred feed of water. Too deep for conventional divers, but not inaccessible. Just hard to get to.

The latest news I saw was from about 10 days ago saying that a salvage company was being contracted with to do the recovery of the two boxes from the tail. Nothing since then.

The NTSB website's latest update was way back on July 5th...

https://www.ntsb.gov/news/press-releases/Pages/mr20210705.aspx

 

[Vanadium 50]

It would be good if they could bring back the engines as well, although of course that is a much more complicated undertaking than the black boxes. It also might not tell us anything. (Engine condition? Like they've been sitting in salt water for a month)

The reason I am thinking along these lines is the economics of airplane engines. The initial cost is low (in some cases actually zero) compared to the required maintenance. So replacing an engine due for service with one that is almost due for service can make sense economically. And right now, with such low demand, such engines are readily available.

Sounds sketchy, I know. But what we are hearing about Rhoades/Transair is that they may be kind of sketchy.

 

[berkeman]

The latest news I saw was from about 10 days ago saying that a salvage company was being contracted with to do the recovery of the two boxes from the tail. Nothing since then.

Looks like this is the company they contracted with (conveniently based in Hawaii), but no news that I can find for how far along they are in the recovery...

Black Box

In any incident like this, the National Transportation Safety Board gets involved immediately. And one of its highest priorities is to recover the Flight Data Recorder, more commonly referred to as the Black Box (even though they’re orange).

But there was a problem: The plane had gone down in water some 420 feet (130 meters) deep. Side-scan sonar was initially used to locate the jet, which had broken apart. And then, the NTSB requested assistance from Sea Engineering Inc., which has two different Remotely Operated Vehicles.

https://dronedj.com/2021/07/12/ntsb-releases-underwater-drone-images-of-hawaii-jet-crash-site/

 

[berkeman]

For some reason they are waiting for the Fall to recover the flight recorders. No idea why...

https://www.staradvertiser.com/2021...-cargo-jet-on-sea-floor-set-to-begin-in-fall/

An undersea effort to recover key components of a Hawaii cargo jet that crashed July 2, leaving its wreckage hundreds of feet under the water, is expected to begin this fall.The U.S. National Transportation Safety Board is coordinating with the insurance company for Transair, the small cargo carrier that was operating the plane, the agency said in an emailed statement.

 

[Dullard]

Fall starts in about 2 weeks?

 

[mfb]

Sure, but the accident has been two months ago. Why was there no attempt yet?

 

[anorlunda]

Sure, but the accident has been two months ago. Why was there no attempt yet?

I don't know, but I can guess. Such recoveries often use specialized submersibles or ROVs. They are transported by ship. So a ship may need to sail halfway around the world to reach the crash site.

 

[Astronuc]

For some reason they are waiting for the Fall to recover the flight recorders.

I believe that Autumn is the quietest period, i.e., less ocean turbulence/current velocity. I was looking for an article that would describe the seasonal variation of undersea currents around Hawaii, but have not found one. There was an article in USA Today that mentioned Autumn as the quietest period, but that is not what I'm looking for.

I was looking for something like - https://www.pacioos.hawaii.edu/currents/model-oahu/, but more along the lines of a yearly/seasonal intensity model.

 

[anorlunda]

I believe that Autumn is the quietest period, i.e., less ocean turbulence/current velocity. I was looking for an article that would describe the seasonal variation of undersea currents around Hawaii, but have not found one.

For surface winds, use the seasonal marine pilot charts. https://msi.nga.mil/Publications/APC

Below are excerpts of the pilot charts near Hawaii, for the months of September and March. In both months, the prevailing winds are NE or E at force 4 (11-16 knots) with 0-2 calm days per month. Both months look almost the same. That's consistent with the NE trade wind zone.

September

March

Currents are more difficult to find at the specific depth of the wreck. Publications give surface currents and deep ocean currents, but this is neither of those.

 

[berkeman]

The latest news I saw was from about 10 days ago saying that a salvage company was being contracted with to do the recovery of the two boxes from the tail. Nothing since then.

The NTSB website's latest update was way back on July 5th...

https://www.ntsb.gov/news/press-releases/Pages/mr20210705.aspx

Well, apparently there was a media briefing on October 9th, but I can't find what was presented anywhere. Here is the announcement about the briefing, and it looks like they are at sea right now actively engaged in the salvage operation:

https://www.ntsb.gov/news/press-releases/Pages/MA20211007b.aspx

 

[Tom.G]

The media briefing can be viewed at:
The delay for recovery was because the wreckage is around 400ft underwater, too deep for divers; and the largest piece weighs 97 000lbs.

The FAA will be implementing a 'Caution' or No-Fly zone in the area because of the large crane needed for the lift.

The aircraft owners insurance company is paying for the recovery and issued an RFQ (Request For Quotes) for salvage operations. Then the recovery ships had to be selected, staffed, outfitted with the needed equipment, and travel to Hawaii.

The video is somewhat entertaining in spots; outdoors on an airport tarmac, on a windy day blowing the script off the podium, with the sounds of planes taking off and/or landing, even a helicopter at one point.

 

[berkeman]

The media briefing can be viewed at:

How were you able to find that video? I searched a fair amount after I found the link I posted that there was a briefing that had been held...

 

[Tom.G]

IIRC, I read the links you provided, one of which mentioned a phrase that stuck with me, along with the date the press conference was scheduled. I did a Google search for the phrase and the date and found the video.

(sorry for the late reply, I was one of 25 residences that lost internet connection about 4:30AM Saturday. It came back at 4:12PM today (Thursday).
a double equipment failure. a part had to be FedEx-ed Priority from Tennessee to Southern California, but there was a weather delay somewhere that slowed things down.)

Cheers,
Tom

(did get a bit more reading done though! by the 3rd day, overall less stressful.)

 

[berkeman]

Finally! It looks like they were able to recover the plane and the two flight recorders in early November. They say the investigation will take 2 years, but hopefully they release some preliminary findings sooner...

https://www.ainonline.com/aviation-...ws-recover-ditched-transair-boeing-737-hawaii

https://www.hawaiipublicradio.org/l...-that-crashed-into-the-ocean-off-oahu-in-july

 

[anorlunda]

It's strange. The black boxes were found November 3, 2021. No news since then. Not even to say that they could, or could not, recover the data.

The NTSB preliminary report was dated 7/2/2021, long before the black boxes were found.

 

[mfb]

The final report was released in June (PDF). Corrosion and possibly prior damage caused two turbine blades to break in the right engine, leading to lower thrust. One of the pilots thought he heard something on the left side and incorrectly assumed they lost the left engine and it looks like both pilots never questioned that. They reduced its thrust to idle, flying only with the damaged right engine - which didn't provide enough thrust. They crashed an aircraft that would have had no problem flying with the left engine.

The captain experienced an engine failure 4 months before the accident. He chose to fly back to the airport immediately at that time, against company procedures, and was told to follow procedures next time. He had also aborted takeoffs in the past when he saw unusually high engine temperatures and was told to ignore them. He saw unusually high engine temperatures again, and followed the order to ignore it.

Video discussing the flight:

 

[russ_watters]

Missed this before:

The final report was released in June (PDF). Corrosion and possibly prior damage caused two turbine blades to break in the right engine, leading to lower thrust. One of the pilots thought he heard something on the left side and incorrectly assumed they lost the left engine and it looks like both pilots never questioned that. They reduced its thrust to idle, flying only with the damaged right engine - which didn't provide enough thrust. They crashed an aircraft that would have had no problem flying with the left engine.

The captain experienced an engine failure 4 months before the accident. He chose to fly back to the airport immediately at that time, against company procedures, and was told to follow procedures next time. He had also aborted takeoffs in the past when he saw unusually high engine temperatures and was told to ignore them. He saw unusually high engine temperatures again, and followed the order to ignore it.

This is very, very rare.... This has happened, as far as I can tell, five times with the 737. Two were double-flameouts in thunderstorms (one as the plane was about to touch down). One was running out of fuel. One was a famous double bird strike (US1549) and one was pilot error: one engine failed and the crew shut down the other one by mistake.

Ding, ding. They didn't shut it down in this case, but rather reduced it to idle and left it there. It's a mind-boggling error. It comes down to performance in emergency situations. The first officer's errors were obviously critical and I think it's likely that due to prior incidents being in his head, the captain made less than optimal choices.

I am surprised by the guidance suggesting being 15 miles out at 2,000 feet and 210 kts was ok. Low and slow with an engine out doesn't provide a lot of margin for error, which they needed here.

 

[DaveE]

It comes down to performance in emergency situations.

More about company policies about safety, training, and procedures, I think. Shutting down the wrong engine is a well known problem that is easily fixed with training, quick reference handbooks, and good crew resource management. A simple engine failure in a 737 is a minor emergency that should be handled reliably with well trained crew.

This would be a very unlikely occurrence at a major part 121 air carrier. This scenario is tested regularly in recurrent training (simulators) at major carriers. You get what you pay for, and this outfit simply didn't care enough to do it right. You can only perform well on the flight deck in emergencies if you have been trained and tested for it.

Of course there's a similar story about maintenance at this carrier.

 

[russ_watters]

More about company policies about safety, training, and procedures, I think. Shutting down the wrong engine is a well known problem that is easily fixed with training, quick reference handbooks, and good crew resource management. A simple engine failure in a 737 is a minor emergency that should be handled reliably with well trained crew.

I didn't intend that to be exclusive of training and prior experience (which is why I mentioned/quoted them), but rather more a 1+1=2 situation. I agree it should be a recoverable error.

 

[DaveE]

I didn't intend that to be exclusive of training and prior experience (which is why I mentioned/quoted them), but rather more a 1+1=2 situation. I agree it should be a recoverable error.

Yes, and I wouldn't necessarily blame the pilots if they weren't properly trained or didn't have good working conditions. Although I don't really think you were. Many pilots go through a phase of working for sketchy carriers. There's a reason it's hard to get hired by a major carrier, and there's a reason they spend a lot of money on training once you do get that job. It might not be a recoverable error if you don't know how work in that situation.

 

[Vanadium 50]

That'll buff right out.

 

[Vanadium 50]

So the two YouTube videos have been highly critical of the pilots. While I wouldn't say they did everything perfectly, I do think they are being unfair.

1. Everybody survived.
2. The f`light was what, 12 minutes? So they had maybe 6 or 7 minutes to diagnose and rectify the problem? If it takes the YouTube videos half an hour to explain, is it really realistic to expect the pilots to be 5x faster? Had they had more time, they would have reached the point on the checklist where they would have verified which engine was bad.
3. A partial engine failure? Do they even train for that?
4. The engines were so old that the captain had experienced multiple failures in his time at TransAir. He was even counseled on what to do next time. Next time? Seriously? If you want a root cause, I would look here - you have an ancient plane with ancient engines, and you are cycling them like crazy.
5. Did the captain spend too much time on the radio? He cleared the airspace he needed, and he alerted the Coast Guard. Had he not done that and had both pilots drowned, would we be saying "Gosh, why didn't he let ATC know he was going down and needed the coast guard?"

In my view, the biggest mistake they made was switching who was the Pilot Flying rather than sticking to their roles and working the problem. Would that have actually made a difference? Probably not.

 

[Flyboy]

4. The engines were so old that the captain had experienced multiple failures in his time at TransAir. He was even counseled on what to do next time. Next time? Seriously? If you want a root cause, I would look here - you have an ancient plane with ancient engines, and you are cycling them like crazy.

dingdingding. You've hit the nail on the head here. These kinds of fly-by-night freight operators are looked at by more... hmmm... conscientious... personnel with a great degree of concern and skepticism. They run on the ragged edge of profitability as it is, so upper management has a (misplaced) incentive to cut costs wherever they can. Instead of saying "Hey, we've got a systemic issue here, maybe we should do a root cause assessment", they just find a way to cheaply bandaid the problem and stick their heads in the sand.

JT8Ds are great engines... if you take good care of them. If you don't, they're just as prone to failure as any other gas turbine engine of their age. And a tropical salt-spray environment is a very harsh place for an airplane, or its engines. Throw in the aforementioned high cycle counts and rates, and it's a textbook environment for accelerated fatigue failures, imo. Just look at the Aloha flight a while back where they lost the whole upper fuselage skin and structure while at cruise. Salt spray environment, high cycle rate and count on the airframe, pressure from management to turn it around fast and cheap. And it cost people their lives when that caught up to them.

 

[Vanadium 50]

fly-by-night freight operators

Literally in this case.

 

[russ_watters]

Literally in this case.

Fly? Yes. Land? No.

 

[Vanadium 50]

The number of landings is strictly equal to the number of takeoffs. The quality of those landings, however, can vary.

Anyone know what became of the pilots? Are they still flying somewhere?

 

[OCR]

Anyone know what became of the pilots?

I believe they decided to switch over to submarines. . . .
.