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MD-81 Dual Engine Failure – Gottrora, Sweden – December 27, 1991
􀂾 On liftoff, clear ice was broken off the wings and ingested by the
engines, damaging the fan stages. This damage lead to the engines
surging
􀂾 The airline company had no knowledge of ATR
􀂾 Without the crew noticing, engine power was increased automatically
through the effect of Automatic Thrust Restoration (ATR) which caused
an increase in the intensity of the surging and contributed to the failure
of the engines
B757 Loss of Control – Puerto Plata, Dominican Republic – February 2, 1996
• During the takeoff roll the CA indicated that his airspeed indicator was
not working
• A few seconds later two advisory messages appeared on the EICAS
display: RUDDER RATIO
MACH/SPD TRIM
• The overspeed warning clacker sounded
• It appeared to start working properly once the aircraft began to climb
but significant discrepancies existed between the CA’s, FO’s, and
alternate airspeed indicators
B757 Loss of Control – Puerto Plata, Dominican Republic – February 2, 1996
• However, the throttles were at too low of a power setting to maintain
altitude
• The autopilot and autothrottles disengaged
• The FO selected Altitude Hold in an attempt to level off and give
them time to sort out what was going on.
• The center autopilot commanded an 18 degree nose up attitude and
the autothrottles were at a very low power setting in response to very
high airspeeds as indicated on the CA’s PFD
• The stall warning “stick shaker” was activated
• Great confusion reigned; power was applied and then removed
more than once
B757 Loss of Control – Puerto Plata, Dominican Republic – February 2, 1996
􀂾 Investigators determined that a pitot tube that provided information to
the left Air Data Computer (ADC) was most likely completely blocked
􀂾 The crew did not attempt to clarify the RUDDER RATIO or MACH/SPD
TRIM advisories but it is unlikely that any related checklists would
have proved useful
􀂾 The left ADC provided information to the CA’s airspeed indicator and
the center autopilot
􀂾 There was no specific airspeed discrepancy warning on the B757
B757 Loss of Control – Puerto Plata, Dominican Republic – February 2, 1996
􀂾 The contradictory warnings and indicators were confusing
􀂾 The center autopilot and autothrottles contributed greatly to their
problems at least initially
􀂾 The crew did not attempt to fly the aircraft manually and continued to
try use automation that did not help them (i.e., Altitude Hold)
􀂾 Although the crew agreed that the alternate airspeed indicator was
correct they continued to try to use (and be confused by) airspeed
information on the PFDs
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Broad, Over-arching Issues
15 Different Categories of Issues:
Selected Emergency Equipment and Evacuation Issues
Issues Related to the Aircraft
Issues Related to Training
Issues Related to Humans
Issues Related to Checklists and Procedures
Training
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Issues Related to Training
Relevant training technologies and approaches
Initial vs. recurrent training in dealing with these situations
Skill acquisition and retention of procedures that are
unpracticed or seldom practiced
Training for “textbook” vs. “nonstandard” situations
Training for handling single vs. multiple problems
Joint training of flight and cabin crews
BAe Jetstream 32 Loss of Control – Morrisville, NC – December 13, 1994
• Crew intercepted localizer ILS approach to runway 5L at Raleigh
Durham – CA was the PF
• During a missed approach procedure, the CA lost control of the
aircraft and it struck terrain – three passengers survived the
accident
• No attempt was made to feather the propeller, secure the engine,
or complete any abnormal or emergency checklists or procedures
• At final approach fix descending through 2,100 ft (640 meters)
an illuminated ignition light led the CA to believe the left engine
had flamed out
• The illuminated ignition light was actually a minor transient
anomaly. Both engines functioned normally throughout the flight
until impact
BAe Jetstream 32 Loss of Control – Raleigh Durham, NC – Dec. 13, 1994
􀂾 Company provided incorrect training by associating the ignition
　
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