• DocumentCode
    2789417
  • Title

    So Much to Learn from One Accident Crash of 737 on 25 February 2009

  • Author

    Hecht, Herbert

  • Author_Institution
    SoHaR Inc., Culver City, CA, USA
  • fYear
    2011
  • fDate
    10-12 Nov. 2011
  • Firstpage
    348
  • Lastpage
    351
  • Abstract
    Turkish Airlines Flight 1951 crashed short of its destination runway at Schiphol Airport, Amsterdam, Netherlands on February 25, 2009. Nine people lost their lives, 177 were injured, and the aircraft was a complete loss. There was an equipment failure in the left radio altimeter that caused the auto-throttle system to go into retard flare mode in anticipation of immediate landing when the aircraft was still near 2000 ft above terrain, There were indications and warnings of this condition to the crew but they were ignored. The throttle retardation was also temporarily masked by the aircraft being directed to intercept the localizer from above, a highly unusual procedure. The investigation found numerous instances of low altitude readings on the accident aircraft as well as on others. Also, the accident aircraft had experienced two instances of throttle retardation on recent flights. Poor reporting practices led the manufacturer and the certifying authorities to underestimate the prevalence of this failure pattern. It is concluded that in many instances actions and design decisions were based on the assumption further conditions will be within the normal envelope. This is a dangerous assumption that must be avoided if we want to maintain the fine safety record of commercial aviation.
  • Keywords
    air accidents; air safety; radioaltimeters; Turkish Airlines Flight 1951; aircraft accident; autothrottle system; equipment failure; radio altimeter; retard flare mode; throttle retardation; Accidents; Air traffic control; Aircraft; Airports; Computer crashes; Instruments; Safety; aircraft safety; failure reporting; human factors; radio altimeter;
  • fLanguage
    English
  • Publisher
    ieee
  • Conference_Titel
    High-Assurance Systems Engineering (HASE), 2011 IEEE 13th International Symposium on
  • Conference_Location
    Boca Raton, FL
  • ISSN
    1530-2059
  • Print_ISBN
    978-1-4673-0107-7
  • Type

    conf

  • DOI
    10.1109/HASE.2011.45
  • Filename
    6113918