Flying across Europe with a BROKEN engine! Smartwings 1125

hi everybody very welcome to mentor and yet another video podcast as always i hope you're doing absolutely fantastic today on the video guys i'm going to start something brand new i'm going to start a series where i look into some famous not so famous incidents and accidents and i'll give you my view of what happens inside of the cockpit and why that happened and we're going to start with the infamous smartwings 1125 that happened almost a year ago now where a f-737 crew had an engine failure on route and instead of diverting and landing as soon as possible they decided to continue the flight for more than two hours across europe why did that happen and what did the final report say stay tuned three one zero one six three one [Music] all right guys so before i start i want to say a huge thank you to my patreon crew and all of my patrons who helped me translate this final report from czech because it's only available in czech into english and because of that translation then because check doesn't really translate exactly into english in some cases there are some stuff in here that might not be exactly as written in the report so if you're a check and you are reading through the report there might be some small differences but all in all a fantastic job by my patreon crew okay thank you very much guys so this flight guys is is interesting from a lot of different perspectives and what i want to try to do in this series is to give my perspective on the perspective of a of a training captain on what went on and i have to say that i have read a lot of final reports in my life but i've never read a final report who has been such an unequivocal rebuke of someone's performance as in it is an absolute takedown of one of the pilots in this crew but let's start from the beginning to tell you about what happened so this is a smart wings 737 800 that flew from the island of samos in greece to prague okay it happened on the 22nd of august last year 2019 and the crew consisted of a very senior captain um he was either a chief pilot or head of operation depending on what translation says of smart wings so high up in the management and a fairly senior first officer the first officer had more than 3000 hours in total and over 2 000 hours on time so it's a very senior crew the aircraft had had some previous problems with engine number one that's on the left-hand side of the aircraft and um but the engineering had you know done what was needed and it had been released for service so it's a it was perfectly serviceable for this flight the crew noticed during the pushback and engine start that the the engine started a little bit slower then the number one start a bit slower than number two however they thought that this had to do with wind conditions on the airport and this is true sometimes when you push back an aircraft and for example you turn into tailwind in that case the wind that's blowing from the back can actually slow down the engine start a bit so this is not uncommon it's not something that i would have noticed or thought about to tax it out they took off normally the first officer was pilot flying and the captain was pilot monitoring and the captain noticed during the the take off raw that the trust setting on the engine number one was about one and a half percent lower end one than on the uh on the right side um he said in the report that he thought that this was negligible however there is a specific briefing for samos because thomas is a very performance limited runway saying that you have to make sure that you have proper n1 set during takeoff from this airport in any occasion anyway the aircraft took off normally it climbed up i clamped to a flight of a 3-6-0 it has had a weight of about 64 tons when it reached flight of a 3-6-0 and almost immediately once they had reached their cruising level um and the number one started spooling back and eventually failed now i have done a video on what happens if an engine fails while you're in cruise and you can you can check out it's going to be a link here and link down in the description of the video but basically what you need to understand is that a 737 or any commercial aircraft is built to fly up to a really high level so in the case of the 77800 we can cruise at 41 000 feet if we're light enough but only if we have two working engines if one engine fails we don't have enough thrust to maintain both speed and altitude and the single engine service ceiling of 727 800 which is the altitude that you can keep on one engine tends to vary between about 23 to 25 000 feet depending on the weight so it is crucial if an engine fails at that altitude that you very quickly monitor decide which engine is a faulty fly the aircraft first and then initiate what we call a drift down procedure which is basically a way to start descending the aircraft down to below its single engine service ceiling the first officer was pilot flying very quickly realized the engine failure applied the correct amount of rudder to keep the aircraft flying and then started to try to communicate with the captain he said several times that they needed to reduce altitude that they needed to descend however there was no response back from the captain right in the report the captain is blaming problems with his headset however that doesn't seem to have been the case later on during the flight so it it's hard to say why the captain didn't respond there but for a full two minutes the aircraft was cruising along one engine at 36 000 feet which meant that the speed crept down to about 226 knots of indicated airspeed and this is still a safe airspeed but you couldn't go much lower than that without starting to get into the the caution amber band of the airspeed at that altitude after about two minutes the first officer managed to convince the captain to initiate the descent however they did not declare a pan-pan now if you have an engine failure right if you were in what we call reduced vertical separation minima airspace or vsm airspace it is mandatory to call a minimum of a pound pan which is an urgency call to let the air traffic control know that you're not able to maintain an altitude and thus be able to clear all traffic below you right it's very very important so either you declare a pan pan which is an urgency call or a mayday which is an emergency call um the difference is that a pound pan means that you need to do something quickly but there's no one there's no immediate danger to the aircraft while uh mayday call means that you know there's a risk of immediate danger for the aircraft or people on board but none of this was called right instead the crew reported a maintenance issue and requested to fly to descend to flight level 240 24 000 feet this also meant that they did not turn off the airway they started descending without clearance to 24 000 feet and they maintained the airway this is important for a couple of different reasons if you have a an emergency descent because of pressurization for example or if you have to descend because of an engine failure and then because of the way that the airways are structured and the fact that you might have traffic just below you on the same airway with only a thousand feet of difference in altitude it's really important that if you start descending without having a clearance to do so that you turn either of 45 degrees which is what we normally do or you do a um a paralleling of the track yes and you turn out and you parallel the airway with maybe two miles uh difference that way you won't be descending into ongoing or paralleling traffic okay this was not done they descended down eventually they got the clearance to do so as they talked about traffic control down 24 000 feet now during the descent the pilot monitoring is the one that's handling the quick reference handbook the checklists and um he started doing the in-flight restart checklist okay now the infrared restart checklist you can do in two different ways either you can do a wind milling start which is basically you're using the airspeed and the airspeed is blowing so much air through the engine that the engine is rotating enough to keep it starting or you can do a crossbleed restart they neglected to start by trying to to use the uh the um the windmilling start so they increased the airspeed to 310 knots and they tried to restart it it didn't work and then almost immediately they tried a crossbreed restart which also failed so at this point they've tried to restart the engine twice it didn't work and at that point you you know you can be pretty sure that there's something severely wrong with this engine that's why it's not starting then the pilot monitoring the captain started going through the engine failure and shut down non-normal checklists all right and it was stated in the report that he did it in a really quick manner so quick that the first officers had problems following the items being done but one thing that is very very clear in that checklist is once you have gone through it once you've set up the aircraft properly for the engine failure it says at the very last point that you have to land at the nearest suitable airport plan to land at the near suitable airport okay so what is the near suitable airport then well when you do your type rating on the 737 you have to read through something called the flight crew training manual this is a manual that is generic made by boeing by boeing test pilot which is stating the best way of handling different scenarios from their perspective and it outlines very clearly what they mean by the nearest suitable airport the same thing is also done in the qh in the beginning of the curate where it stated how to read the checklist and basically it says that the near suitable airport is the nearest airport that is still safe to land at so you have to take into account for example no times if there's something going on if the runway is closed for example or if the runway is shorter than normal you have to look at the weather if the weather is within operating minimus and if that's the case well then it's a suitable airport there's nothing in there about for example operational support or if it's economically viable for the airline or anything like that to just a safety kind of consideration in here so when they came to that point the the captain quite quickly decided that they should be continuing towards prague okay they were looking at different unroot alternates for example they had tessaroniki um they decided without that's not explained in the report why they decided that wasn't suitable they had the budapest but they also had vienna which is a big commercial airport just on their route the captain decided that that wasn't suitable because of traffic reasons now it should be said that if you declare a mayday or a pan-pan call you have priority so traffic is not really an issue you will always get the priority in to land at the an airport like vienna for example if you're coming in with an engine failure there's no question about that and the captain knows this all right now instead they decided or he decided to continue towards prague which was a full two hours and nothing 11 minutes away okay and this is after the engine failure the first officer was not happy with this not at all um he tried several times to highlight the plan to land at the near suitable airport point in the cure age but after a few times where the captain was dismissive of this he basically decided that in the name of crew resource management and you know keeping the cockpits kind of feeling better he decided to go with the piloting command's decision which you know the palestine command is the one that has the last word in this however in this case it was it was obviously a very very strange decision to make okay but on top of this they still have not issued a pan pan or mayday so a traffic control has no idea that they have an engine failure they just know that they have some kind of maintenance issue and they want to go down to 24 000 feet that could be anything it could be a pack not working so that they want to go down there in order to you know to help the pressurization for example um so they continue to fly now if you're gonna go and fly for over two hours there is when we calculate what we call a take-off alternate there is a rule that states that you need to have a take-off alternate within one hour of single engine flying time and that 396 nautical miles because that's what they're counting on now there is a possibility that the captain thought of that to say okay so you can fly for one hour single engine so then you can probably fly for two hours because there's no definitive rule here how he reasoned regarding this and the fact that you could continue to fly is impossible to know all right it states clearly in the report that they couldn't they couldn't rule out that he was thinking about the economical impact to the airline when it was deciding to continue to prague but they couldn't prove it either and what is true though is that if he would have gone in and done some proper fuel calculations he would have realized that they would have reached prague without having sufficient fuel to do a diversion to an alternate okay the problem here of course is that he did not do this so in the um in the quick reference handbook in the engine failure shutdown checklist it says that you are not allowed to use fmc fuel predictions and the reason for this is that the fmc who does normally very good fuel predictions doesn't know that the aircraft is single engine and doesn't know that the fact of single engine means that the aircraft is now flying a little bit with a crab angle you know it has a bit of rudder in so it's crabbing a bit and it's also having a dead engine that's not producing any trust but is producing drag and because of that it is burning much more fuel and obviously also at a lower flight level okay so it says clearly do not use the fmc for fuel prediction instead you have to go into the performance in-flight chapter in the qra and see the altitude and weight you are what kind of fuel burn you can expect you can also do a quicker variant of this which is just going in and checking the fuel flow of the remaining engine see how long in time you're going to be flying and then just calculate how much fuel you need because that's going to be accurate none of this was done instead he checked the fmc the fmc said that they're going to land with sufficient fuel and they continue he did three fuel cross checks on the remainder of the flight but he didn't do any recalculation of the fuel nor did he do any kind of of just evaluation of the decision to continue to prague right nothing the cabin crew got involved in this case as well they noticed that something was happening uh the captain said in his testimony for the final report that he had told them to do a visual inspection of the engine the cabin crew was adamant saying that he did not say that to them did not tell them to do that they talked about what kind of um pa they needed to do to the passengers and they decided that they were going to do a just a general pa about a technical failure but they will continue into prague now this is not uncommon it should be said because when we discuss about what we have to say and not to the passengers you tend to give them enough to to motivate what's happening and to tell them what's going on without giving too much details because if you do it's likely that just gonna increase the anxiety level in the cabin so if i say that we have a technical problem with one of our engines which necessitate us to divert to get engineering attention in vienna that's enough detail but if i go in and i say we've lost one engine or we have an engine failure on the left-hand side and we are now going to go down to try to get help down in vienna that's just going to increase the anxiety level it's not something that you want you just want to make sure that the passengers know what's going on and that you you empower your cabin crew so that they listen to the cabin crew in case there would be some kind of emergency briefing needed they also decided that there was no need for preparing for an evacuation which is also completely normal under these circumstances they made a pa they continued to fly there there was no more mentioning to atc about emergency or maybe until they got into prague um the prague atc area and the tma where the crew decided to finally declare pan-pan in order to get priority in for landing so it's interesting here that the captain decided to to call upon pan to get priority into prague but did not think about calling pam pan to get priority into vienna which is kind of a little bit going against what he was saying before they didn't normal flaps 15 single-engine landing in prague they taxed it off and when they got into to gate the engineers were waiting for them because they had told the engineering eight cars that they had this engine failure he didn't do any proper tech log entry about the failure he told engineers about it and he and this is crucial guys did not pull the cvr circuit breaker and the cvr circuit breaker is what what stops the cockpit voice recorder from recording and you have to remember that the cockpit voice recorder only has two hours of recording on it so there are certain things like engine failures tcas resolution advisories or um problems with the pressurization or faulty read backs and level busts things like that that's really really really serious that has to by law be preserved right the cvr needs to be pulled in order for a subsequent investigation like this to be able to know how the crew was reacting and how they were discussing he didn't pull this even though his own manuals that he was a part of writing stated that that needed to be done okay so what happened then obviously is that the engineers solved the the engine problem and then the aircraft continued to fly and the next flight just overwrote whatever was on that tape so the the final report did not have access to the cbr for this data which is really really uh serious okay right so so this is basically what happened no one got hurt there was no injuries however the final report that just came out just last week is a stunning rebuke of the performance of the captain all right in general terms normally a final report is only there to state exactly what has happened in a factual term and then give safety recommendations so it will tell the airline for example to do certain things it will tell the engineering department to do certain things and it will tell in some cases the pilots to do certain things but in most cases it only tells the training department of the airlines okay make sure your pilot knows about this or increase the training about this but in this case they actually went in to detailed performance reviews of the involved pilots so for the first officer they basically said that he had handled the situation well he inputted him right amount of rather he tried to tell the captain to to initiate descent he eventually got that to happen he didn't feel that he um that he could he didn't feel that the crm allowed him to speak up more than he actually did this was a point where they actually did tell the fo that he should become more assertive he needs to speak up no matter how high the cockpit gradient is but apart from that basically did a good job same with the cabin crew did what they were supposed to um the the company itself got some recommendations regarding training a pilot however when it came to the pilot in command and remember that this is the head of operation or the chief pilot or at least at the time he got he he was taken away from that position after this incident well they start from the very beginning saying that uh there were some obvious problems with his headset communication and that were unclear whether or not that had to do with wiring with the headset or if it just wasn't any problem with the headset they couldn't establish that um then they said they um the the pilot command did not properly monitor the n1 settings during the take-off roll which was mandatory as part of the um the airport brief that they were flying out of samos then he also ignored the requests from the first officer to initiate the descent when the engine failure occurred of flight for 360. and it said that that decision or the fact that he did not communicate well with the first officer increased the stress level a lot in the cockpit which could have led to other mistakes during the actual following descent then they as a crew and him as being the public monitoring specifically did not call a pan pan or a mayday call during the descent and the fact that they then continued to descend without clearance initially endangered the aircraft around them and there was no proper fuel or engine performance calculations done throughout this this whole ordeal they did not and specifically the captain did not use the quick reference handbook secure age in a proper way he did not read it carefully and didn't follow the advice or the actual mandatory step of plan to land at near suitable airport the captain did not follow established crm rules and principles as outlined in the crm manual that he himself had been part of writing and they did not kind of have any risk management strategy threat and error management strategy and if you guys have seen my video about how to do piosi then you know that there is established kind of rules and frameworks for how to do this that was not follow um they decided to continue to prague despite that there were obvious um lacks in their fuel calculations and there was actually doubts about whether or not they would have enough fuel to do such a long flight over two hours single engine and during this whole flight there was no more than three fuel checks recorded and no continuing re-evaluation of whether the aircraft was burning more fuel than anticipated which obviously should have been done um they didn't deform the passengers in a sufficient manner according to the according to the report they the captain said that he had told the cabin crew to do a visual inspection of the engine the cabin crew said that he did not do so and they did not pull the cvr circuit breaker nor did they put a relevant entry into the technical logbook once the flight was completed okay all of this together was was brought to the attention of the captain and the investigators basically asked him so how do you think what do you think about your performance in the way that this flight was handled and his response was that he thought that he had sufficient experience and time on the aircraft in order to evaluate all associated risks that the aircraft could get itself into and in this case the safety of the flight or safety of any other flights around it was never compromised that was essentially what he said and because the investigators had showed all of this data to him and he responded in that way they basically ordered a psychological evaluation of the captain saying that you know we have to check if this person actually is sane right and i've never in my life when i've been and i've been reading a lot of final reports in my life never seen that happening it's never seen such a complete rebuke of the performance of one single crew member in one incident so basically they're saying that this was not done well it was several things lacking most of the problems emanated from the incompetence of the the captain in this case um and because of the way that this is written there's now a criminal investigation against the captain i don't know how far that has become i don't know if he has been removed from flying i know that he lost his chief pilot or head of operation position after this incident but he was allowed to continue in the role of both the captain and typewriting instructor and i think it's an examiner as well i don't know if that's been changed when this final report came out um but it is it is a stunning read i'm going to actually link to the english translation that my patreons once again did below this video it's really interesting to read and there's a lot to be learned here guys basically it shows that there are still these type of pilots around who do believe that they're god's gifts to aviation that no matter what the manual says no matter what the rule says what crm says um they think that they know better and we have to these these these pilots just needs to be weeded out um they you know they have nothing to do in a modern cockpit this is not a safe way to handle an incident like this there are established ways that should be done and that's the way to do it guys this was just one out of thousands of incidents accidents that's been out there i would love to hear what you want me to talk about if there's more emphasis you want me to do on certain things for example tell me in the comments to this video what incidents and accidents or occurrences it is that you want me to talk about now i will be limiting myself to incidents that has been concluded so where there's been a final report released so that's worth thinking about but do tell me and also make sure that you have signed up to mentorpilot.com you you can come in and you can become a member at different levels so if you become a cadet member it's completely free of charge but you will be given perks there's going to be for example you'll be able to access my discord server where me and my patrons are doing a lot of discussing now if you are on the cadet level you reach up to a certain kind of standing in the discord server my paying members in metropolitan.com and my patreons are at a slightly higher level but i want to create this community together with the mentor aviation app to make sure that you have a place where you can put your flying pictures in your merch pictures where you can ask questions and talk about aviation and just have this fantastic aviation kind of community going so go to metropolitan.com register yourself get yourself into the discord server start talking to me or do the same inside of the mentor aviation app doesn't matter i just want to be able to discuss with you and let you be part of this community have an absolutely fantastic day wherever you are and i'll see you next time bye-bye right guys i really hope that you liked that if you want more content like that more aviation content but then check this out uh i hope that you have subscribed to the channel and that you've highlighted the little notification belt see you inside of the mentor aviation app and have an absolutely fantastic day bye [Applause] [Music]

Channel: Mentour Pilot

Views: 765,761

Keywords: Smartwings, Smartwings 1125, Pilot, Aviation news, Final report, Breaking aviation news, Mentour Pilot, Mentour Pilot Boeing 737, Mentour Pilot Boeing 737MAX, How to become a pilot, pilot training, pilot life, Boeing 737, Boeing 737MAX, Boeing 787, Airbus A320, Airbus A380, Airbus A350, Boeing 747, Fear of flying, Aircrash investigation, Aviation incident, nervous flyer, nervous flyer help, how to become a pilot, Breaking news, bitcoin, financial news

Id: 0ga8UFy1M04

Length: 29min 16sec (1756 seconds)

Published: Sat Aug 01 2020