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Author Topic: AA 1646 - Pilot error, CRM failure and resulting problems for ATC (with comms)  (Read 7746 times)
iskyfly
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« on: May 01, 2012, 03:50:33 PM »

Apologies if this was posted in any of the forums. I did a search for 1646 but couldn't find anything.

AA 1646 departs DFW. Shortly thereafter while passing through 14,000 feet the crew elects to return to airport.
In the background of the comms you can hear an alarm sounding in the cockpit.

Apparently it was because the pilots misconfigured the packs / bleeds.

Furthermore, the crew had to make two go arounds and 2 360's (one into the direction of departure traffic).

http://avherald.com/h?article=43b47d30



Discussion points;

1- Failure to properly config pressurisation before take off.
2- Lack of CRM resulting in two go arounds.
3- Is there something else here that has not gone reported? Lack of pressurization itself should not have caused the crew to get behind the aircraft on two consecutive approaches. Stay low, and hold while going through the QRH before commencing approach.
 

Discuss.
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StuSEL
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« Reply #1 on: May 01, 2012, 06:54:05 PM »

Given that this incident happened over a year ago, I think we can all trust that American Airlines has implemented steps to prevent this from happening again. I'm not exactly sure what we're supposed to analyze here. Obviously this was the crew's fault.

I have no idea why you would say "stay low" in this situation because it is quite literally the antithesis of what is taught in instrument flight programs. In the event of an emergency, except when commencing a final approach to land, the advice is always to stay high so as to avoid terrain and obstacles. Given that this was the Dallas TRACON, if pilots have an emergency and are in contact with ATC, their assigned altitude will always be above the MVA. If not in contact with ATC, they would have to climb to a published MEA or OROCA, or maintain VFR.
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CFI ASEL
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iskyfly
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« Reply #2 on: May 01, 2012, 08:46:12 PM »

Given that this incident happened over a year ago, I think we can all trust that American Airlines has implemented steps to prevent this from happening again. I'm not exactly sure what we're supposed to analyze here. Obviously this was the crew's fault.
Seeing as that you replied I guess you did feel there was something to discuss as it pertains to this incident. And if you watched the video (which I get the impression you didn't) you would see that the lessons of this incident have indeed been addressed by AA and are now incorporated in its training curriculum.

Quote
I have no idea why you would say "stay low" in this situation because it is quite literally the antithesis of what is taught in instrument flight programs.
Lets see. You are in an aircraft that is not pressurising, so what do you do? Keep climbing? Is that what is taught in instrument flight programs? No. Stay low (meaning don't climb higher). Run the QRH.

An example of good CRM for a far more complex problem occurred when QF32 experienced a turbine failure that also degraded two other engines, damaged hydraulic and fuel lines, landing gear and flight controls. What did the crew do? They flew a holding pattern while they addressed ECAM actions and landed about an 1 hour 45 minutes after the turbine ruptured.

So why did a lack of pressurization cause the crew of AA 1646 to miss twice and also steer into the direction of departing aircraft?
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StuSEL
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« Reply #3 on: May 02, 2012, 11:22:58 AM »

So why did a lack of pressurization cause the crew of AA 1646 to miss twice and also steer into the direction of departing aircraft?
Is this honestly something you expect us to answer here, or are you looking for armchair speculation? Unless one of the forum posters was a crew member that day, this isn't a question we're capable of tackling.

Seeing as that you replied I guess you did feel there was something to discuss as it pertains to this incident. And if you watched the video (which I get the impression you didn't) you would see that the lessons of this incident have indeed been addressed by AA and are now incorporated in its training curriculum.
I watched the video in its entirety. What you quote me as saying is an expansion on discussion points (1) and (2) you posted.

Quote
I have no idea why you would say "stay low" in this situation because it is quite literally the antithesis of what is taught in instrument flight programs.
Lets see. You are in an aircraft that is not pressurising, so what do you do? Keep climbing? Is that what is taught in instrument flight programs? No. Stay low (meaning don't climb higher). Run the QRH.
In my experience flying Cessna aircraft, I have gone up to as high as 11,500 feet without pressurization or supplemental oxygen while remaining in full compliance with FAA regulations and my body's own limitations. From this experience, I realize that pressurization is not a necessity to sustain life at low altitudes. I would imagine there would be problems, perhaps, with air conditioning or something that relies on pressurization to function, but it would be more life threatening to remain at a low altitude and hit something than to climb and sort out the situation. I say again, as they say in real world flight programs: in an emergency, altitude is your friend, and you should climb.

An example of good CRM for a far more complex problem occurred when QF32 experienced a turbine failure that also degraded two other engines, damaged hydraulic and fuel lines, landing gear and flight controls. What did the crew do? They flew a holding pattern while they addressed ECAM actions and landed about an 1 hour 45 minutes after the turbine ruptured.
I'm not suggesting the crew would get an A+ on CRM in the original incident. I'm not sure why you followed up with this.
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CFI ASEL
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iskyfly
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« Reply #4 on: May 02, 2012, 11:36:36 AM »

So why did a lack of pressurization cause the crew of AA 1646 to miss twice and also steer into the direction of departing aircraft?
Is this honestly something you expect us to answer here, or are you looking for armchair speculation? Unless one of the forum posters was a crew member that day, this isn't a question we're capable of tackling.

Please don't speak for everybody. I think it is a fair topic for discussion. If you have nothing of value to add to the discussion then don't reply.

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but it would be more life threatening to remain at a low altitude and hit something than to climb and sort out the situation. I say again, as they say in real world flight programs: in an emergency, altitude is your friend, and you should climb.
So lets apply your training to this situation- You are saying that when you are at 14,000 feet with an aircraft that is not pressurising, to continue to climb?

An example of good CRM for a far more complex problem occurred when QF32 experienced a turbine failure that also degraded two other engines, damaged hydraulic and fuel lines, landing gear and flight controls. What did the crew do? They flew a holding pattern while they addressed ECAM actions and landed about an 1 hour 45 minutes after the turbine ruptured.
Quote
I'm not suggesting the crew would get an A+ on CRM in the original incident. I'm not sure why you followed up with this.
For your edification.
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StuSEL
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« Reply #5 on: May 02, 2012, 11:40:52 AM »

So lets apply your training to this situation- You are saying that when you are at 14,000 feet with an aircraft that is not pressurising, to continue to climb?
No sir/ma'am. I said you should NOT "stay low" in an emergency. I was correcting your misinformed over generalization.

See ya.
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CFI ASEL
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iskyfly
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« Reply #6 on: May 02, 2012, 01:12:43 PM »


No sir/ma'am. I said you should NOT "stay low" in an emergency. I was correcting your misinformed over generalization.

See ya.


Oh, we have to go back to the replay for you;


Quote
3- Is there something else here that has not gone reported? Lack of pressurization itself should not have caused the crew to get behind the aircraft on two consecutive approaches. Stay low, and hold while going through the QRH before commencing approach.

There was nothing generalized or misinformed about that as it was specific to this incident.

Heck, even you knew that;
I have no idea why you would say "stay low" in this situation

Do you have an idea now?
« Last Edit: May 02, 2012, 01:16:43 PM by iskyfly » Logged
StuSEL
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« Reply #7 on: May 02, 2012, 03:58:39 PM »

...
« Last Edit: August 31, 2013, 01:06:45 AM by StuSEL » Logged

CFI ASEL
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