Loss of control and poor CRM cited in fatal Ethiopian Boeing 737 accident near Lebanon

January 17, 2012

Flight ET409 flight profile

The Lebanese Ministry of Public Works & Transport released their investigation progress report regarding the January 2010 fatal accident involving a Ethiopian Flight 409 off the coast of Beirut.

On January 25, 2010 a Boeing 737-8AS (WL) passenger jet, registered ET-ANB, was destroyed in an accident 6 km southwest off Beirut International Airport (BEY), Lebanon. All 82 passengers and eight crew members were killed. The airplane operated on Ethiopian Airlines flight ET409 from Beirut International Airport (BEY) to Addis Ababa-Bole Airport (ADD).

The flight departed at night on an instrument flight plan. Low clouds, isolated cumulonimbus (CB) and thunderstorms were reported in the area. After take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315°. ET 409 acknowledged and heading 315° was selected on the Mode Control Panel (MCP). As the aircraft was on a right turn, Control suggested to ET 409 to follow heading 270° “due to weather”. However, ET 409 continued right turn beyond the selected heading of 315° and Control immediately instructed them to “turn left now heading 270°”. ET 409 acknowledged, the crew selected 270° on the MCP and initiated a left turn.
ET 409 continued the left turn beyond the instructed/selected heading of 270° despite several calls from ATC to turn right heading 270° and acknowledgment from the crew. ET 409 reached a southerly track before sharply turning left until it disappeared from the radar screen and crashed into the sea about five minutes after the initiation of the take-off roll. The flight recorder data revealed that ET 409 encountered during flight two stick shakers for a period of 27 and 26 seconds. They also recorded 11 “Bank Angle” aural warnings at different times during the flight and an over-speed clacker towards the end of the flight. The maximum recorded AOA was 32°, maximum recorded bank angle was 118° left, maximum recorded speed was 407.5 knots, maximum recorded G load was 4.76 and maximum recorded nose down pitch value 63.1°.

Probable causes:

  1. The flight crew’s mismanagement of the aircraft’s speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
  2. The flight crew failure to abide by CRM principles of mutual support and calling deviations hindered any timely intervention and correction.

Contributing factors:

  1.  The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
  2.  The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
  3.  The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.
  4.  The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
  5.  The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain’s performance.
  6.  The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.
  7.  The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.
  8.  Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
  9.  The F/O reluctance to intervene did not help in confirming a case of captain’s subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator’s SOP.

More information:

Day 2 of EASA Safety Conference: “Staying in Control – Loss of Control (LoC) – Prevention and Recovery”

October 5, 2011

EASA Conference Day 2

The European Aviation Safety Agency (EASA) today, October 5, opened the second day of their third aviation safety conference. The conference was  attended by 250 professionals from the aviation industry.

The theme for the two-day conference is “Loss of Control”. A topic well chosen because Loss of Control (LoC) accidents are considered a safety priority by many organisations.

The U.K. CAA for instance named LoC as one of the “Significant Seven” issues that affect airline safety. The CAA’s efforts with regards to LoC focus on training and assessment of pilot monitoring skills, use of aircraft automation and maintenance of manual flying skills.

These issues were also raised by several other speakers. Several industry-wide committees and working groups are working actively on all fronts – Prevention, Detection, and Recovery with regards to LoC.

One of those joint efforts was to make a generic procedure for pilots how to handle a stall at low altitude. Past training focused to prevent altitude loss, many times leading the pilot to add maximum thrust as the first step for recovery. The new focus however is on CRM, making it a team effort to recover from stall instead of a pilot flown maneuver. An industry-wide group completed a new and generic procedure that has been verified and validated by Airbus and Boeing.

The stall recovery template as presented by Boeing and Airbus

Simulator training

Also, there is a  need for changing flight simulator training in relation to key issues involved in LoC accidents. Simulators today are satisfactory for teaching upset prevention but can cover an estimated 1/3 of what they need for teaching upset recovery.

For instance, events caused by atmospheric disturbances and flight control issues can be replicated in simulators. Disorientation though is harder to replicate. And for icing and stalls simulators are not up to the full job. Yet, those two account for a large amount of Upset accidents; almost half of all accidents according to research.

Research is being done in the European SUPRA projects with enhancing motion cueing in existing flight simulators and a new advanced simulator at TNO labs which can simulate continuous g-loads and even inverted flight.

Something to which everyone agreed is that is no single solution to Loss of Control; only a multifaceted approach to Prevention, Detection, and Recovery will reduce LoC  accidents.

There is a vital role for instructors. Also general aviation instructors should use this guidance in their training for future airline pilots.

The conference presentations will be published on the EASA conference website.

Meanwhile, a video of Dr. Sunjoo Advani’s excellent presentation during a previous conference is available online:

Presentations held during Day 2 were:

Stall Recovery: New international Standard
Claude Lelaie, (Flight Test Pilot, Airbus retired) and Philip Adrian, 737 Chief Technical Pilot, Chief Pilot Regulatory Affairs, The Boeing Company

Upset Recovery Training
Philip Adrian, 737 Chief Technical Pilot, Chief Pilot Regulatory Affairs, The Boeing Company and Capt Marc Parisis, VP Training and Flight Operations Support, Airbus

FAA Stall and Upset Recovery Training Initiatives
Capt Robert Burke, Aviation Safety Inspector, Air Carrier Training Branch, FAA

Flight Simulator for Upset Recovery
Dr Jeffery Schroeder, Chief Scientist and Technical Advisor for Flight Simulation Systems, FAA

Loss of Control: Significant Threat – Significant Actions
Capt David McCorquodale, Head of Flight Crew Standards, UK CAA

The ICATEE Programme
Dr Sunjoo Advani, Royal Aeronautical Society / Chairman of the ICATEE

Supra Project
Dr Eric Groen, SUPRA Technical Coordinator, TNO and Lars Fucke, SUPRA Dissemination Lead, Boeing R&T Europe

NASA Research on LoC
Dr Christine Belcastro, Chief Scientist, NASA

Summary – Way Forward and Conclusion
John Vincent, Deputy Director for Strategic Safety & Head of Safety Analysis, EASA

Day 1 of EASA Safety Conference: “Staying in Control – Loss of Control (LoC) – Prevention and Recovery”

October 4, 2011

EASA's safety conference

The European Aviation Safety Agency (EASA) today, October 4, opened their third aviation safety conference. The conference is being attended by 250 professionals from the aviation industry.

The theme for the two-day conference is “Loss of Control”. A topic well chosen because Loss of Control (LoC) accidents are considered a safety priority by many organisations.

This was again confirmed by speakers today. EASA research of airliner accidents over the past decade showed that 25% of all fatal accidents are caused by Loss of Control. Additionaly, ICAO data supports the conclusion that LoC accident account for most fatalities. It is one of four safety priorities for ICAO.

And alarmingly, the LoC accident rate is not decreasing.

But how to decrease the number of LoC accidents? ICAO suggests that it should be a global approach with harmonization of efforts. Meanwhile several organisations are involved in research in relation to (aspects of) LoC. Some speakers noted that the monitoring skills of the ‘pilot monitoring’, or ‘ pilot not flying’ should be strengthened. With enhanced monitoring skills a copilot could be even better prepared to anticipate and recognize signs that, for instance a stall is imminent.

But not it is not just monitoring skills.  A French study in 2008 reported that many copilots felt that they were not adequately prepared for surprising situations.

It should be considered to take these kind of situations into account during pilot training. Especially given the growing automation on today’s flight decks. It is getting harder to anticipate all different failure modes in these automated systems. More so since several systems like Electronic Flight Bags do not go through the same certification processes as aircraft systems.

However, a slight change in training would not be sufficient, according to Jean Pariès. He even suggested a paradigm shift for training as a whole to, “”recognize real world unpredictability.. and to maintain/develop resilience features”.


Several LoC accidents were mentioned by different speakers. These accidents were:

23 Aug 2000 – A320 at Bahrain: nose down input by the captain during a night time go around; crash into the sea.

22 Dec 1999 – B747F near London-Stansted: captain lost control when his ADI failed.

23 Sep 2007 – B737-300 near Bournemouth, UK. Unrecognized disengaing of autothrottle during final approach.

14 Sep 2008 – B737-500 near Perm, Russia:  loss of spatial orientation of the crew during night time approach, pilot not familiar with Western ADI’s.

25 Feb 2009 – B737-800 near Amsterdam-Schiphol Airport: Stall following undetected autothrottle thrust reduction during final approach.


Day 1 of the conference featured the following speakers:

Welcome Speech – Opening Remarks
John Vincent, Deputy Director for Strategic Safety & Head of Safety Analysis, EASA

Keynote Speech
Patrick Goudou, Executive Director, EASA

EASA Rulemaking Forewords
Jean-Marc Cluzeau, Head of Flight Standards Department, EASA

EASA Safety Review – Loss of control accidents in numbers
Ilias Maragakis, Safety Analyst Expert, EASA

Accidents in Commercial Aviation Transport: Review and lessons learned
Capt Bertrand de Courville, Air France Corporate Safety Manager, ECAST Co-chair

Loss of Control Examples
Margaret Dean and Andrew Blackie, Senior Inspectors of Air Accidents (Operations), AAIB UK

Crew Resource Management
Jean Pariès, President, Dédale SAS

Flight Path Management Systems: Policy, Training and Operational use
Dr Kathy Abbott, Chief Scientific and Technical Advisor, Flight Deck Human Factors, FAA

EASA Automation Policy
Dr Michel Masson, HF Expert / Safety Action Coordinator, EASA

ICAO Activities in relation to LoC
Henry Defalque, Technical Officer, Licensing and Operations, Flight Operations Section, ICAO

Report: Spatial disorientation caused Kenya Airways B737-800 loss of control accident

April 28, 2010

Flight profile of flight KQ507 after takeoff from Douala

The fatal accident involving a Boeing 737-800 operated by Kenya Airways in May 2007 was caused by spatial disorientation and a loss of control, according to the Cameroon Civil Aviation Authority (CCAA) investigation.
The airplane crashed at night shortly after takeoff from Douala Airport (DLA), Cameroon, killing all 114 on board.

The CCAA report indicated that there was lack of crew coordination as flight KQ507 climbed into the dark knight. There were no external visual references, yet no instrument scanning was done. At 1000 feet climbing, the pilot flying released the flight controls for 55 seconds without having engaged the autopilot. The bank angle of the airplane increased continuously by itself very slowly up to 34 degrees right and the captain appears unaware of the airplane’s changing attitude.

Just before the “Bank Angle” warning sounds, the captain grabbed the controls, appeared confused about the attitude of the airplane, and made corrections in an erratic manner increasing the bank angle to 50 degrees right.

At about 50 degrees bank angle, the AP is engaged and the inclination tends to stabilize; then movements of the flight controls by the pilot resume and the bank angle increases towards 70 degrees right. A prolonged right rudder input brought the bank angle to beyond 90 degrees. The airplane descended in a spiral dive and crashed into a magrove swamp.

PROBABLE CAUSE: “The airplane crashed after loss of control by the crew as a result of spatial disorientation (non recognized or subtle type transitioning to recognized spatial disorientation), after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night.
Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the AP, have also contributed to cause this situation.”

FAA asks ARAC for recommendations on low speed alerting systems

April 3, 2010

The U.S. Federal Aviation Administration (FAA) assigned the Aviation Rulemaking Advisory Committee (ARAC) a task to identify and develop recommendations on additional requirements for low speed alerting in new transport category airplanes.

The action was triggered, amongst others, by the fatal accident involving a DHC-8-400 of Colgan Air in February 2009. All 49 on board were killed when the airplane stalled and crashed while on final approach to Buffalo, NY.

With respect to low speed alerting, the FAA previously revised regulations in the area of flight guidance (autopilot) and performance and handling qualities in icing conditions to improve transport airplane standards for low speed protection (in the case of icing, stall warning standards were enhanced).

ARAC is initially tasked with providing information that will be used to develop standards and guidance material for low speed alerting systems. This information may result in standards that complement existing stall warning requirements. The working group will be expected to provide a report that addresses the following low speed alerting technical questions:

  • How much time is needed to alert the crew in order to avoid stall warning or excessive deviation below the intended operating speed?
  • What would make the alerting instantly recognizable, clear, and unambiguous to the flightcrew?
  • How could nuisance alerts be minimized?
  • Could the alerting operate under all operating conditions, configurations, and phases of flight, including icing conditions?
  • Could the alerting operate during manual and autoflight?
  • Could the system reliability be made consistent with existing regulations and guidance for stall warning systems?
  • Are there any regulations or guidance material that might conflict with new standards?
  • What recommended guidance material is needed?
  • After reviewing airworthiness, safety, cost, and other relevant factors, including recent certification and fleet experience, are there any additional considerations that should be taken into account?
  • Is coordination necessary with other harmonization working groups (e.g., Human Factors)? (if yes, coordinate and report on that coordination)

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