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Incident: Qatar B788 at Doha on Jan 10th 2023, steep descent after takeoff (avherald.com)
67 points by mji 47 days ago | hide | past | favorite | 102 comments

> The occurrence was not reported to the authorities and only came to light later.

This is shocking, heads in the sand.

If they don't report it they don't have to pull the cockpit recorder lever and after 1 1/2 hours there is no trace of their fumble except their own reports...

I understand the reasoning for the 'black box' to have limited storage. I do not understand the reasoning that supports lack of a trace log to retain in the face of turbulence and other possible lawsuit generating events such as this.

The Blackbox records over the whole flight. I am only talking about the cockpit voice recorder. It's the best indicator to see how something went down in the cockpit after an incident were the flight crew lost situational awareness.

Why not pair the limited storage with something more long lasting? The long-lasting could be a heavy-duty ssd that holds 8tb or something. That is weeks worth of audio and data. If that's lost in a crash or incident, so be it, it was probably severe incident and the 1.5 hour backup is all that's needed anyway.

Exactly what I was suggesting. A non-disaster storage media that doesn't need the rigor of the expensive and limited solution already present for disaster diagnosis.

Blackbox is only for accident cases

For the day to day there is a recording system called FOQA which can (and does) get analyzed, and stores more or less the same thing as the blackbox

Of course trying to be sneaky doesn't help when ATC noticed what happened

My understanding is, various aircraft/airlines have logging facilities with longer memories, just it's up to the airline to look through them.

Normally if you're looking at a black box, you know something suboptimal already occured.

Commercial have digital twins these days, RR’s entire business model relies on having always on real time telemetry from all of its engines because it doesn’t sell engines anymore it leases flight hours so they have a digital twin for each RR engine in service and they predict when parts and servicing needs to happen and make sure that an alternative engine(s), parts and service crew will be available just in time.

Uh the telemetry is pretty unusual. That gets broadcast. And the airline's HQ would see this in real-time.

Yeah, but if they don't report and no one from their company "sees" it they don't have to pull the circuit...

No trace, except for the cabin crew and the logs kept by ATC.

In situations like these you get the most information from the voice recorder. You can't abstract a lot about what really happened in the cockpit from telemetry and the cabin crew is not in the cockpit.

This is a minor incident. I don't think they would have been asked to return to the gate over this.

> ...recovered about 800 feet above water

the way I read it, there were only 800 ft (less than 250 m, or around 15 seconds at a sink rate of 3000 fpm) standing between a "minor incident" and a major disaster.

"As any real racer would tell you, whether you win by an inch or a mile, winning is winning".

Almost crashing your airplane is always a major incident in commercial aviation.

Yeah, but they would have to break the circuit if they report an incident.

And this is against all regulations and guidelines for about every company.

Shocking, and why it happened in the first place. Not reporting and investigations a near miss automatically is a strong signal of bad systematic safety problems.

It's cultural.

which in itself isn't shocking

> heads in the sand.

Quite literally?

That's an unnecessary stereotype

Would you be saying that if it was some quip about Canada being cold?

We're talking about a carrier based in a desert nation and a flight that departed said desert nation. It's a joke about the local environmental conditions resulting in the phrase "head in the sand" being potentially ambiguous between the literal meaning and the figurative meaning.

How is this a stereotype?

I live in the Middle-east (the region of the world where Doha is located), trust me, it’s full of sand.

You don’t need to feel insulted for me.

It’s just fucking tasteless. It very nearly happened.

The original use of the idiom was mine and I didn’t make that connection at all.

Ah and your use of the “f” word is full of taste. Grandiose.

Reading the thread under that suggests I will be starting an airline shitlist effective immediately.

You’ll have a very short list of carriers left not on the list, if any.

Human error happens with much greater frequency in aviation than you might believe - I have experienced some absolutely hair-raising moments (watched Lufthansa lose a winglet on landing while the stewardess prayed, had an aerolinias argentinas flight take off with a luggage compartment still open, and a air Bishkek flight where the wheels locked on landing and we ground down the runway at sheremetyevo on hubs), and have been told tales of others by pilots that I wish I hadn’t been told.

The thing is, most of the time, it’s nothing more than some scared passengers and a messed up schedule. “Almost” didn’t happen.

Yeah I know a couple of pilots, one of whom does "flying scum buses" as he calls them to hot places around Europe and have a lot of horror stories. Nothing major: bits of planes falling off, people going bananas, near misses etc.

I generally don't fly these days and haven't actually been in a plane for 20 years (ex wife couldn't fly due to med issue) but I need to get out there and would like to pick the least shitty solution.

Two more to add to the list. Brand new passenger aircraft on final approach to landing and the control tower tells the pilot they've forgotten to lower the landing gears. Worse case outcome, clear good weather condition, passenger aircraft approaches landing and gets it wrong, crash and burn, passengers survive on the ground and some get runover by the fire trucks arriving on scene.

I’ve driven an airport fire appliance and that doesn’t surprise me in the slightest - I could not see a damned thing for 20 meters in front of me on the ground, as the window is a thick glass slit mounted above eye level, as it’s designed to be driven into and withstand a jet fuel fire - you have to stand and drive to see where you’re going - and that was in clear broad daylight.

Human error is just part of it.

Some environments foster correction of such errors, learning, experience-sharing, pay well for parts and maintenance, don't overwork their staff. Others not.

I think for me such insights would be gold.

You might be interested in https://airlinelist.com which tracks accident statistics of many airlines. Made by Pieter Levels of the Nomadlist fame.

The problem with lists of major accidents is they aren't necessarily a predictor of future accidents, and in some cases may be the reverse. An airline suffering a major accident is likely to lead to a significant safety overhaul.

What's needed is a service that tracks near misses or mistakes such as in this post, and their trend over time for each airline. An increase in frequency for a particular airline might well be usefully predictive.

> The problem with lists of major accidents is they aren't necessarily a predictor of future accidents, and in some cases may be the reverse. An airline suffering a major accident is likely to lead to a significant safety overhaul.

This should be a somewhat testable proposition, right? Does time since accident increase or decrease the probability of next accident?

(Practically, plotting the distribution of inter-accident durations and seeing if the tail falls off exponentially, slower, or faster.)

There is no methodology or details or anything. How does number of accidents relate to number of planes operated, or number of flown miles? What constitutes an "accident"? Do terrorist bomb plots count? Do incidents where the airline could not be be blamed count (e.g. MH17)? Is an accident from 30 years ago still counted? Czech Airlines scores quite low, but the last fatal accident was in 1977; so if these older accidents are counted then why is IcelandAir listed with "no accidents" even though they had one in 1978?

And how is "eco-friendly" or "service" measured? Why does AtlasGlobal score quite well on Safety even though it's ranked quite low in here, while SCAT airlines – with the same number of "odds of fatal accident" – does have a very low safety score?

Sorry, but useless website. Actually, worse than useless because it pretends to be informational but it's not as the actual amount of information is minimal beyond "trust me" and even a basic scrutiny of a few minutes shows up all sorts of inconsistencies and oddities.

It's almost as if "how safe is an airline?" is a complex question that requires expertise and analysis instead of a website with a few lines of JavaScript conjured up by some programmer guy...

Yeah I agree this site is not the definitive answer to the question of airline safety with all its nuances. Like you said, in the end it is a work of just one person and it is perhaps more for entertainment value than information content, because you still have to take it with a huge grain of salt if you meant to make any serious decisions based on it.

But it is good enough for an inspiration to start a tongue-in-cheek airline shitlist the person I was replying to mentioned. At least I got a joky vibe from their comment. Perhaps they were super serious in that they were gonna start one right this second?

Emirates, no accidents? I would say this one (https://en.wikipedia.org/wiki/Emirates_Flight_521) definitely qualifies as an accident, although the only fatality was an unfortunate firefighter...

I used the Feedback button in the bottom right to let Pieter know so that he can update the site. Thanks for letting me know!

The safest carriers are those that have just been founded recently, by this logic. Since they have no incident history.

According to this website, Air Asia is supposedly safer than Singapore. And Xiamen Airlines are safer than Cathay? CX and SQ have one of the best safety records, each only suffered a single hull loss, which is very little considering how long they've been operating.

Air Asia is not even a single operation but a bunch of separate airlines using the same brand for marketing purposes. Some of them have much worse safety record than the others (Air Asia Indonesia for example). One would think this also warrants a mention, considering KLM is labeled "Air France-owned" (which is sort of true but much less relevant). Also for consistency shouldn't Transavia then be labeled "Air France-owned" and not "KLM-owned?" Or maybe Air France should be labeled "KLM-owned" to give the more complete story.

In any case, it would be much more useful to know which airlines are government-owned, since this usually breeds regulatory collusion (especially if the regulator and the head of the airline happen to be the same person).

Anyone can put up a list on the Internet but this one is really misleading. If you want a better picture of airline safety comparison (still with many caveats), there's this one:


What airline does not see pilots, crew and maintenance as just another cost point that needs optimization to the max in order to satisfy shareholders and investors?

In the US and plenty of places the airline regulations are strong and followed well. NTSB reports have nothing to do with shareholder value and FAA directives are followed. Not that there are no problems, but flying in the US is very safe.

Boeing 737 MAX disasters says otherwise, especially when after the first crash the decision was made not the ground all others which was clearly in favor of profits over safety.

The accidents may not have been American airlines but it could have easily been.

Southwest. Honest answer.

Southwest is belabored by very strong unions. Unreasonable demands in reality from the pilots

Southwest's pilots union has been somewhat weak with negotiations if anything. A lot of their pilots are super unhappy about it. The market is strong for pilots right now and they're behind their peers at the Big 3 by quite a bit in a lot of areas.

What are the unreasonable demands?

Not sure how far the information is true but I am told many Middle eastern carriers do not get sufficiently mature pilots & have to make do with junior ones. Or it could be possible that they compensate for some of the luxurious offerings with invisible cutting corners like pilot experience. Either way there seems to be a certain issue which needs addressing.

I remember reading on HN where the pilot failed to timely rotate the plane when it was supposed to take off until it had overshot and apparently flew at 200+ kts after taking off from DBX at low altitude (75 ft) for about a mile, before climbing up & proceeding without incident to IAD [1][2]. Admiral Cloudberg blogged that Emirates 521 incident showed Emirates pilots seemed over-reliant on instrument for landing [3].

[1] https://avherald.com/h?article=4f24b2d7

[2] https://onemileatatime.com/news/emirates-terrifying-boeing-7...

[3] https://admiralcloudberg.medium.com/the-reliability-trap-the...

I don't know of a single airline not to have had any sort of incident. So you'll have to take the boat to cross the oceans next time you need to visit another contient :)

Proper airlines only please.

Are you implying Qatar isn’t a proper airline? Anyone who flies international often would likely rate it at the highest levels currently. My current lowest ranked crap airline is British. God have the Europeans grown lazy.

There's a difference between the onboard service and cabin (and god are BA shit), and the flight safety.

That said BA earned a hell of a black mark when it chose to divert to Heathrow rather than Stansted or even Gatwick when its engine was on fire [1]. Not as much as when Air France decided to divert from Lebanon to Damascus in the middle of a civil war rather than Cyprus because it was cheaper [2]

[1] https://www.standard.co.uk/news/london/ba-flight-returns-to-... [2] https://globalvoices.org/2012/08/26/france-an-epic-flight-fr...

> That said BA earned a hell of a black mark when it chose to divert to Heathrow rather than Stansted or even Gatwick when its engine was on fire

After declaring an emergency, if they landed at Heathrow, that was at the pilot's discretion or due to limiting factors like runway length at Gatwick and the weight of their plane. The article is light on detail but they circled over Kent as well, so the pilots must have thought it was safe after shutting down the engine.

In the process dropping debris over one of the largest cities in Europe.

Gatwick and Stansted can take any plane just as easily as Heathrow, but has less on ground resources to fix the plane.

Runway length at LGW is OK for a 777.

I'd guess they knew it was safe and it's easier to deal with a plane full of pax at your originating airport than diverting to STN (where there's no BA ops) or LGW (BA have ops here so could have worked).

> STN (where there's no BA ops)

BA did fly from STN in 2017, at the time of the incident - they served short haul tourist routes like PMI, AGP, FLR, IBZ.

Honestly I’ll take the incremental odds that I’ll be the unlucky guy in the first ever Qatar plane crash over the absolute dogpile BA calls service now (having just received my missed business class bag after a full week of no communication or updates).

I'd rather have a safe bad experience than a shiny plane crash.

What plane crash?

The 787 was less than 250 m above water, that was VERY close to crash.

The only difference being at 600 feet above water, the olane could, and did, continue its journey. At zero feet, not so much.

Safety and customer experience are two different things that may not correlate much most of the time. I'll rather have top quality pilots and maintenance than friendliest flight attendants if I have to choose between two.

I prefer a pleasant flight than to fly a shitty airline.

And as a frequent flyer of European airlines for intercontinental flights, the quality of the flight experience pales in contrast with Qatar.

You don't know how good the pilot is until it gets you out of a really bad situation that the AP cannot manage. Most airline pilots do very little actual flying: takeoffs mostly, and depending on how new the plane is and the type of runways they land on, some just use auto-land systems.

You're most likely to find more experienced pilots flying small commercial planes without AP than actual proper airline pilots.

Your last two statements are not accurate.

Autoland is not the common landing method unless you're in very poor visibility. Pilots DO use it in good weather or other situations, but that's mostly to keep current on their certifications for its use. For those who are curious, look up Category III (Cat III) or 0/0 approaches. Those are the ones autoland are intended for.

Secondly, amongst pretty much every common definition of experience "small commercial plane" operators are almost always less experienced than airline pilots, at least in the US. The reason for this is simple, to be a commercial pilot you need 250 hours of flight experience. To be an airline pilot you need 1500. Small commercial businesses are commonly where pilots pick up the experience needed to even apply to be an airline pilot.

Other common sources: 1) Flight instructing (also a small commercial gig), 2) The military, 3) Aviation schools and lots of $$$$

> Most airline pilots do very little actual flying: takeoffs mostly, and depending on how new the plane is and the type of runways they land on, some just use auto-land systems.

And that's precisely why I also care about pilot quality before how pleasant the service is. The moment something goes awry with the automated systems you better have a good crew flying your plane than a crew who's much more reliant on instruments and automation.

It's like insurance, I'd rather choose to never have to use it but the moment I need it you bet I'll be very grateful that I preferred a very good coverage than the cheapest option out there.

Agreed on most parts, but at some point you have to start deciding whether the safety tradeoff is worth it. You’re still more likely to die on the car ride to the airport than in the plane, yet we all do it still. And the “quality” of service is not just slightly off, it’s wildly off to the extent it genuinely distresses you even when everything is going right, leave alone the hell British creates if even something goes wrong. Again, until something actually crashes I’ll reserve judgement on whether the slight increase in supposed risk for the middle eastern airlines is even real.

The increased risk people are talking about have been demonstrated in the form of crashed airliners.

The entire rubric of reporting deviations early and often was developed as it was identified as a major cause of crashes in the 60s, 70s, 80s and 90s.

Per this particular incident: It is a big deal the FO screwed up. It's a bigger deal that the screwup was not reported, as it's an indication that the culture of the airline is more concerned with reputation than keeping everyone alive.

Check out the comments from the article. Of course most of us have no way of verifying that information.

> At about 1600 feet the aircraft was cleared direct to the next waypoint and the first officer attempted to turn towards that waypoint flying manually and without flight director indications (the captain was slow to put the Direct into the FMS) but lost situational awareness sending the aircraft into a descent that reached 3000 fpm sink rate and exceeded the flap speed limits until the captain took control of the aircraft and recovered about 800 feet above water.

Kinda hard to believe that he simply “lost SA”. For an instrument/commercial pilot to lose SA at night on an instrument plan is hard to believe. I’d love to hear the cockpit voice recorder and see the detailed telemetry. Was there a distraction in the cockpit? Interpersonal conflict? A stall?

> Kinda hard to believe that he simply “lost SA”.

It's just a euphemism for incompetent instrument flying.

> For an instrument/commercial pilot to lose SA at night on an instrument plan is hard to believe.

Accident reports do show that this level of incompetence from instrument rated commercial pilots do exist. See for example Atlas Air Flight 3591.

Perhaps it's not that common, but of course there's sampling bias here: we're filtering for the pilots that screwed up, so of course there's a lower level of incompetence there.

Well, it has happened before (https://en.wikipedia.org/wiki/Air_France_Flight_447), and it was hard to believe then too. Ok, in that case the situation was compounded by pitot tube icing, but that alone shouldn't bring down an aircraft in the 21st century...

> For an instrument/commercial pilot to lose SA at night on an instrument plan is hard to believe

If one relies on comments from AVH, Qatar might not have the best practices out there. Inappropriate culture could turn to bad results. Plus there is no information for First Officer's flight experience. He could be a less experienced one.

Context - In the dark, it's hard to tell the difference between acceleration and pitching up.

True - without being able to see outside the airplane (because of darkness, clouds, fog etc.) it's easy to get disoriented. That's why airplanes have instruments (the attitude indicator, a.k.a. artificial horizon) that pilots are taught to rely on rather than trusting their own "gut feeling" about what the plane might be doing. Guess this copilot needs some additional training...

If only planes had some kind of measuring devices that could tell their angle from the horizon and their speed through the air

While flying manually is important to keep skills sharp, trying to fly this under VFR would not be a good idea

When you fly at night, even in VFR mode, you trust the instruments over what you think you see.

Pilot fatigue comes to mind immediately. Just reading in AVH that qatar pilots often fly 120 hours a month and in flight rest is not counted.

How’d the FA not even feel this? 3000fpm at climb throttle would probably not feel like it should! Probably a little noisy too? Lucky they didn’t exceed any speed thresholds, especially on flaps which I imagine were still deployed

They went above flap speed limits.

> ...lost situational awareness sending the aircraft into a descent that reached 3000 fpm sink rate and exceeded the flap speed limits until the captain took control of the aircraft and recovered about 800 feet above water.

i get the impression you would a have hard time holding a job as a commercial pilot if you follow the rules strictly and are super cautious

this is due to some conflicting interests between absolute safety and a commercial airlines unstated priorities

No, that's not true. Not following the rules strictly around duty time is a great way to have the FAA up your ass.

but it literally says that the pilots didnt report it.

At the same level of competency with air France 447...

Disaster Breakdown video of the accident for anyone interested: https://www.youtube.com/watch?v=Jsch6vFlcE4

Are airlines lowering their standards due to labor shortages, or are they overworking their pilots?

There are over 100,000 commercial flights per day around the world. Flying is very safe but statistically, shit happens.

Or are people flying more so there are more opportunities for incidents?

You sure haven't read the incident report on that disaster, did you? It is not even the same aircraft model, not even the same manufacturer...

It's the training of the first officer that is the questionable in both incidents.

While that was a contributing factor in the AF case (I didn't look up the other one), it is far from the only one. Stating it like the FO training being, kind of, the only factor is over simplifying things a lot. Exactly what isn't happening with aviation incidents.

Have you read the AF447 report? The FO lacked basic airmanship skills, such as not stalling own plane and not knowing pushing the nose down to increase airspeed.... he would have failed PPL licence in a Cessna.

Sure, it was not the only factor, but it was one of the decisive factors.

The comment section in TFA suggests it's not surprising with Qatar Airlines, or indeed with Middle Eastern airlines (I have no idea).

I mostly think of airline safety as binary, eg passing basic standards or not. Is there some data to understand the shades of grey in-between?

Standards change wildly between countries and/or companies. Culture can also effect this a lot. For example strict respect for seniority in the culture where a person lower on the org chart will never ever question their superiors actions/opinions.

Also some companies do not have access to good maintenance/parts due to economic sanctions on their country of origin (or just lack of money). Though this should not be a problem for Qatar Airways.

Flight safety is about keeping up with a large number of factors. Someone surely has collected accident rates by region, nation, airline, etc.

Basically only airlines in advanced western nations get an automatic pass for me, the rest treated with suspicion and research if I had to fly with one.

>>> only airlines in advanced western nations get an automatic pass for me

This site https://airlinelist.com/ was posted earlier and has a section to track airlines by accidents. Except Virgin Airline you will see no other "advanced" western airline in the list of safe airlines! You should take a deep breath and reflect on your automatic trust in advanced western airlines, you might find it stems from an unconscious bias!

I wonder what the criteria is, BA is marked for a fatal accident... in 1985 (and I could be pedantic and point out that was a subsidiary, British Airtours). JAL also in 1985, El Al in 1977. ANA? 1971. I'm not sure if those are going to be as relevant to judging the modern safety practices of the airlines.

Also, what's the your criteria for "advanced"? Ryanair and Easyjet have no fatal accidents on that site, are you just counting long haul "proper" airlines with wide bodies and not short haul budget operators?

Please see my other comment before taking the above linked "list" seriously:


For years there's been another ranking with much better methodology:


Although there are still caveats, with the main one being that past performance does not directly translate to future results, especially if there were significant changes to the airline situation in the meantime. Checking the recent reports from the Aviation Herald can also be revealing:


To be fair the big difference between Virgin (and Qatar, Emirates, etc.) and other major western airlines is that they were founded in the 80’s not in the 1920’s. Planes used to drop out of the sky all the time.

The list of "very safe airlines" there has lots of Western airlines. Having no history of accidents does not equal being safe, actually useful measure is number of accidents per flight hours (and even that is only useful for big airlines).

Anyway, even something like Qatar is fairly safe. To avoid REALLY unsafe airlines one should consult this list https://transport.ec.europa.eu/transport-themes/eu-air-safet...

I see Qantas, which is a western airline by most definitions.

Though it's worth noting that Qantas have been acquiring smaller companies then slapping their badge on the planes and their uniforms on the pilots. It's only a matter of time before they start to slip down this list and regress to the mean.

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